Pediatric Tonsillectomy and Ketorolac

Phillips-Reed, Lesley D.; Austin, Paul N; Rodríguez, Ricardo Escudero

doi:10.1016/j.jopan.2015.02.005

Cited by 13 publications

(12 citation statements)

References 15 publications

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“…We had a reoperation rate of 1% for each cohort, which is similar to that reported in the literature . The lack of a difference between protocols is consistent with recent studies showing that ketorolac does not increase risk for posttonsillectomy hemorrhage in children …”

Section: Discussionsupporting

confidence: 88%

“…NSAIDs are highly effective analgesics, but have historically been avoided for T&As due to concerns for bleeding . However, several of our surgeons have studied NSAIDs and posttonsillectomy hemorrhage—recent studies and systematic reviews suggest that while ketorolac increases the risk of posttonsillectomy hemorrhage in adults, this is not the case for children …”

Section: Introductionmentioning

confidence: 99%

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The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery—A quality improvement project

Franz

Dahl

Huang

et al. 2019

Pediatric Anesthesia

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Pain management following pediatric tonsillectomy and adenotonsillectomy surgery is challenging and traditionally involves perioperative opioids. However, the recent national opioid shortage compelled anesthesiologists at Bellevue Surgery Center to identify an alternative perioperative analgesic regimen that minimizes opioids yet provides effective pain relief. We assembled an interdisciplinary quality improvement team to trial a series of analgesic protocols using the Plan-Do-Study-Act cycle.Initially, we replaced intraoperative morphine and acetaminophen (M/A protocol) with intraoperative dexmedetomidine and preoperative ibuprofen (D/I protocol).However, when results were not favorable, we rapidly transitioned to intraoperative ketorolac and dexmedetomidine (D/K protocol). The following measures were evaluated using statistical process control chart methodology and interpreted using Shewhart's theory of variation: maximum pain score in the postanesthesia care unit, postoperative morphine rescue rate, postanesthesia care unit length of stay, total anesthesia time, postoperative nausea and vomiting rescue rate, and reoperation rate within 30 days of surgery. There were 333 patients in the M/A protocol, 211 patients in the D/I protocol, and 196 patients in the D/K protocol. With the D/I protocol, there were small increases in maximum pain score and postanesthesia care unit length of stay, but no difference in morphine rescue rate or total anesthesia time compared to the M/A protocol. With the D/K protocol, postoperative pain control and postanesthesia care unit length of stay were similar compared to the M/A protocol. Both the D/I and D/K protocols had reduced nausea and vomiting rescue rates. Reoperation rates were similar between groups. In summary, we identified an intraoperative anesthesia protocol for pediatric tonsillectomy and adenotonsillectomy surgery utilizing dexmedetomidine and ketorolac that provides effective analgesia without increasing recovery times or reoperation rates. K E Y W O R D S analgesics, anesthesia, dexmedetomidine, ketorolac, quality improvement, tonsillectomy | 683 FRANZ et Al.

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Section: Discussionsupporting

confidence: 88%

Section: Introductionmentioning

confidence: 99%

The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery—A quality improvement project

Franz

Dahl

Huang

et al. 2019

Pediatric Anesthesia

View full text Add to dashboard Cite

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“…247,248 The use of ketorolac in tonsillectomy patients remains limited due to concerns of increased bleeding postoperatively. [247][248][249] Anesthesia providers and surgeons have been reluctant to use ketorolac in patients undergoing tonsillectomy, arguing that ketorolac may contribute to postoperative bleeding secondary to an alteration in the normal clotting mechanism through inhibition of platelet aggregation. 248 However, a 2013 review from the Cochrane Collaboration 244 comparing ketorolac with other NSAIDs found no increased risk of bleeding.…”

Section: Supporting Textmentioning

confidence: 99%

“…[247][248][249] Anesthesia providers and surgeons have been reluctant to use ketorolac in patients undergoing tonsillectomy, arguing that ketorolac may contribute to postoperative bleeding secondary to an alteration in the normal clotting mechanism through inhibition of platelet aggregation. 248 However, a 2013 review from the Cochrane Collaboration 244 comparing ketorolac with other NSAIDs found no increased risk of bleeding. Studies in children have not found a significant risk for PTB in those administered ketorolac as compared with adults.…”

Section: Supporting Textmentioning

confidence: 99%

“…It is not associated with common opioid side effects, such as respiratory depression, nausea/vomiting, urinary retention, or sedation. 247,248 The use of ketorolac in tonsillectomy patients remains limited due to concerns of increased bleeding postoperatively. [247][248][249] Anesthesia providers and surgeons have been reluctant to use ketorolac in patients undergoing tonsillectomy, arguing that ketorolac may contribute to postoperative bleeding secondary to an alteration in the normal clotting mechanism through inhibition of platelet aggregation.…”

Section: Supporting Textmentioning

confidence: 99%

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Clinical Practice Guideline: Tonsillectomy in Children (Update)

Mitchell

Archer

Ishman

et al. 2019

Otolaryngol.--head neck surg.

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499

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Objective. This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children \15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.

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Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single‐Center Retrospective Propensity‐Matched Study

Feldman,

O'Reilly‐Shah,

Dahl

et al. 2023

Otolaryngol.--head neck surg.

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ObjectiveTo determine if perioperative ketorolac is associated with an increased rate of reoperation for hemorrhage after pediatric tonsillectomy at 30 days and 48 hours.Study DesignSingle‐center retrospective propensity‐matched study.SettingQuaternary pediatric hospital and ambulatory surgery center.MethodsPatients less than 18 years old undergoing tonsillectomy or adenotonsillectomy between January 1, 2015 and October 1, 2020 were included. Hemorrhage rates between exposed (K+) and unexposed (K−) patients were calculated for the total cohort and a 1:1 propensity‐matched cohort. Additional analyses included: multivariable logistic regression, subgroup analysis of ASA 1 and 2 patients, subgroup analysis comparing children with teenagers.ResultsThere were 5873 patients (42.1% K+) in the full cohort and 4694 patients in the propensity‐matched cohort. Reoperation for hemorrhage within 30 days occurred in 1.9% of K+ patients and 1.6% of K− patients (P = 0.455) in the full cohort and 1.9% of K+ patients and 1.7% of K− patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.72‐1.69, P = 0.662) in the propensity‐matched cohort. Reoperation within 48 hours occurred in 0.65% of K+ patients and 0.53% of K− patients (P = 0.679) in the full cohort and 0.68% of K+ patients and 0.51% of K− patients (OR 1.33, 95% CI 0.63‐2.81, P = 0.451) in the propensity‐matched cohort. There was no association between perioperative ketorolac administration and reoperation for hemorrhage in any of the other analyses.ConclusionKetorolac at end of surgery should be considered as part of the nonopioid analgesic regimen for pediatric tonsillectomy.

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Pediatric Tonsillectomy and Ketorolac

Cited by 13 publications

References 15 publications

The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery—A quality improvement project

The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery—A quality improvement project

Clinical Practice Guideline: Tonsillectomy in Children (Update)

Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single‐Center Retrospective Propensity‐Matched Study

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