Postoperative Bleeding Associated with Ibuprofen Use after Tonsillectomy: A Meta‐analysis

Stokes, William A; Swanson, Robert T.; Schubart, Jane R.; Carr, Michele M.

doi:10.1177/0194599819852328

Cited by 38 publications

(43 citation statements)

References 31 publications

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“…According to Stokes et al, none of the previous literature on Ibuprofen use post-tonsillectomy contained measures that proved that the patients were given the prescribed medications. 13 Finally, our study could have been improved by collecting data over the course of more than 18 months to ensure that the results of our novel treatment plan did not regress to the previous mean, and that improvements were sustained over many years and many different surgeons.…”

Section: Discussionmentioning

confidence: 99%

“…2 A meta-analysis was carried out in 2019 which suggested a slightly elevated incidence of bleeding when Ibuprofen was used for post-tonsillectomy analgesia and suggested a multi-institutional RCT is needed to determine if Ibuprofen actually increases the risk of PTH. 13 Because of the importance of this concern, a Quality Improvement study with regard to Acetaminophen and Ibuprofen dosing was carried out in our practice in order to see if we could rapidly improve patient outcomes for those undergoing tonsillectomy. We hypothesized that reducing the total doses of Ibuprofen would improve PTH rate.…”

Section: Introductionmentioning

confidence: 99%

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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: Discussionmentioning

confidence: 99%

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%

“…22 Another meta-analysis found increased bleeding with ibuprofen but required a sample size of 319,305 patients to reach significance. 21…”

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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“…Consistent with our current study, the authors were able to detect a statistically significant increase in PTH, with a similar OR of 1.38. 24…”

Section: Discussionmentioning

confidence: 99%

Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

Leung

DeVore

Kawai

et al. 2020

Otolaryngol.--head neck surg.

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Objective To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database. Study Design Retrospective cohort study. Setting The study was conducted using the Pediatric Health Information System (PHIS) database. Methods Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region. Results Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 ( P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735). Conclusion The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.

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Postoperative Bleeding Associated with Ibuprofen Use after Tonsillectomy: A Meta‐analysis

Cited by 38 publications

References 31 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)

Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

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