Evaluation of post-tonsillectomy hemorrhage with use of ... · Tonsillectomy and...
1
Tonsillectomy and adeno-tonsillectomy • Second most common pediatric procedure in the US • Reduces health care costs for patients with sleep disordered breathing and recurrent pharyngitis Adverse Events • Postoperative nausea • Postoperative dehydration • Insufficient pain control • Hemorrhage AAO-HNS practice guidelines 1 • “Post-tonsillectomy hemorrhage rates with ketorolac range from 4.4% to 18%, and therefore ketorolac use should be avoided” • “NSAIDs, ketorolac excluded, can be safely used for the postoperative treatment of pain following tonsillectomy” Post-operative analgesia: Ketorolac/opioid vs. morphine alone • Obtaining analgesia while reducing risk of respiratory depression BACKGROUND Benjamin Metcalfe DO 1 , Mamie Higgins MD 2 , Melissa Ehlers MD 1 , Jason Mouzakes MD 2 Department of Anesthesiology 1 , Department of Otolaryngology 2 , Albany Medical Center – Albany, New York Evaluation of post-tonsillectomy hemorrhage with use of intraoperative ketorolac in the pediatric population RESULTS Overall postoperative hemorrhage rate with intraoperative use of of ketorolac tromethamine: 4.7 % National post-tonsillectomy hemorrhage rate: 2 – 6% National post-tonsillectomy hemorrhage rate with intraoperative ketorolac: 4.4 – 18% METHODS l Retrospective chart review, Jan - Dec 2011 l 3 – 18 yrs old l Single fellowship-trained surgeon l All bilateral tonsillectomy or tonsillectomy plus adenoidectomy l ASA physical status 1 & 2 l Standardized operation: l Extracapsular, used monopolar electrocautery l 0.5 mg/kg IV ketorolac given intraoperatively l Dexamethasone 0.4 mg/kg IV intraoperatively l Ondansetron 0.1 mg/kg IV intraoperatively l All patients were intubated and received inhalational anesthetic. Most received fentanyl 0.5 mcg/kg IV l Post-operative analgesia (after discharge): ibuprofen, acetaminophen with or without codeine Level 1 hemorrhage • Any report of post-operative hemorrhage, with or without clinical evidence • 8/422 = 1.9% Level 2 hemorrhage • Required inpatient admission • 4/422 = 0.9% Level 3 hemorrhage • Cases with return to the OR • 8/422 = 1.9% OBJECTIVES To evaluate the post-tonsillectomy hemorrhage rate in patients receiving intraoperative ketorolac at our institution and compare to national average. Ketorolac is an effective analgesic option that did not demonstrate increased post-tonsillectomy hemorrhage rates compared to published rates without NSAID use in the healthy pediatric population examined here. These findings encourage a re-evaluation of current practice guidelines given the risks associated with other analgesic options in this subset of patients CONCLUSION DISCUSSION • 75% of levels I and II bleeds – indication for surgery was infectious (e.g. chronic tonsillitis or recurrent strep pharyngitis) • Retrospective study; no control group • Lack of perceived need for better post-operative pain control? • Many surgeons aware of risks of ketorolac but limited knowledge of benefits REFERENCES 1. Baugh RF, Archer SM, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30. Doi: 10.1177/0194599810389949 2. Aggrawal A, Gerson CR, et. al. Postoperative hemorrhage after tonsillectomy: Use of ketorolac tromethamine. Otolaryngol Head Neck Surg 1999;120:335-9 3. Cardwell ME, Siviter G, Smith AF. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2005 (2):CD003591. 4. Judkins JH, Dray TG, Hubbell RN. Intraoperative ketorolac and posttonsillectomy bleeding. Arch Otolaryngol Head Neck Surg. 1996; 122:937-940.
Transcript of Evaluation of post-tonsillectomy hemorrhage with use of ... · Tonsillectomy and...
Tonsillectomy and adeno-tonsillectomy• Second most common pediatric procedure in the US• Reduces health care costs for patients with sleep disordered
breathing and recurrent pharyngitisAdverse Events• Postoperative nausea• Postoperative dehydration• Insufficient pain control• HemorrhageAAO-HNS practice guidelines1
• “Post-tonsillectomy hemorrhage rates with ketorolac range from 4.4% to 18%, and therefore ketorolac use should be avoided”
• “NSAIDs, ketorolac excluded, can be safely used for the postoperative treatment of pain following tonsillectomy”
Post-operative analgesia: Ketorolac/opioid vs. morphine alone
• Obtaining analgesia while reducing risk of respiratory depression
BACKGROUND
BenjaminMetcalfeDO1,MamieHigginsMD2,MelissaEhlersMD1,JasonMouzakes MD2
DepartmentofAnesthesiology1,DepartmentofOtolaryngology2,AlbanyMedicalCenter– Albany,NewYork
Evaluation of post-tonsillectomy hemorrhage with use of intraoperative ketorolac in the pediatric population
RESULTS
Overall postoperative hemorrhage rate with intraoperative use of of ketorolac tromethamine:
4.7%
National post-tonsillectomy hemorrhage rate:2 – 6%
National post-tonsillectomy hemorrhage rate with intraoperative ketorolac: 4.4 – 18%
METHODSl Retrospective chart review, Jan - Dec 2011l 3 – 18 yrs oldl Single fellowship-trained surgeonl All bilateral tonsillectomy or tonsillectomy plus adenoidectomy
l ASA physical status 1 & 2l Standardized operation:
l Extracapsular, used monopolar electrocauteryl 0.5 mg/kg IV ketorolac given intraoperativelyl Dexamethasone 0.4 mg/kg IV intraoperativelyl Ondansetron 0.1 mg/kg IV intraoperativelyl All patients were intubated and received inhalational anesthetic. Most received fentanyl 0.5 mcg/kg IV
l Post-operative analgesia (after discharge): ibuprofen, acetaminophen with or without codeine
Level 1 hemorrhage• Any report of post-operative hemorrhage, with or without clinical
evidence• 8/422 = 1.9%
Level 2 hemorrhage• Required inpatient admission• 4/422 = 0.9%
Level 3 hemorrhage• Cases with return to the OR• 8/422 = 1.9%
OBJECTIVES
To evaluate the post-tonsillectomy hemorrhage rate in patients receiving intraoperative ketorolac at our institution and compare to national average.
Ketorolac is an effective analgesic option that did not demonstrate increased post-tonsillectomy hemorrhage rates compared to published rates without NSAID use in the healthy pediatric population examined here.
These findings encourage a re-evaluation of current practice guidelines given the risks associated with other analgesic options in this subset of patients
CONCLUSION
DISCUSSION
• 75% of levels I and II bleeds – indication for surgery was
infectious (e.g. chronic tonsillitis or recurrent streppharyngitis)• Retrospective study; no control group• Lack of perceived need for better post-operative paincontrol?• Many surgeons aware of risks of ketorolac but limited
knowledge of benefits
REFERENCES1. Baugh RF, Archer SM, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30. Doi: 10.1177/01945998103899492. Aggrawal A, Gerson CR, et. al. Postoperative hemorrhage after tonsillectomy: Use of ketorolac tromethamine. Otolaryngol Head Neck Surg 1999;120:335-93. Cardwell ME, Siviter G, Smith AF. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2005 (2):CD003591.4. Judkins JH, Dray TG, Hubbell RN. Intraoperative ketorolac and posttonsillectomy bleeding. Arch Otolaryngol Head Neck Surg. 1996; 122:937-940.
