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JAMA OtolaryngologyHead & Neck Surgery | Original Investigation

Association Between Ibuprofen Use and Severity


of Surgically Managed Posttonsillectomy Hemorrhage
Pamela A. Mudd, MD, MBA; Princy Thottathil, MD; Terri Giordano, DNP, CRNP, CORLN; Ralph F. Wetmore, MD;
Lisa Elden, MD; Abbas F. Jawad, PhD; Luis Ahumada, PhD; Jorge A. Glvez, MD, MBI

Editorial page 649


IMPORTANCE Ibuprofen used in postoperative management of pain after tonsillectomy has Author Audio Interview
not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The
severity of bleeding is difficult to quantify but may be a more important outcome to measure.

OBJECTIVE To evaluate the association between ibuprofen use and severity of PTH using
transfusion events as a marker of severity.

DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study identified 8868
patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the
tertiary academic Childrens Hospital of Philadelphia. Of these patients, 6710 met the
inclusion criteria. Data were collected using electronic database acquisition and query.

MAIN OUTCOMES AND MEASURES Multivariate analysis was performed to identify


independent prognostic factors for PTH and receipt of transfusion.

RESULTS Of the 6710 patients who met criteria for analysis (3454 male [51.5%] and 3256
female [48.5%]; median age, 5.4 years [interquartile range, 3.7-8.2 years]), 222 (3.3%)
presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients
required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of
222 patients undergoing sPTH (6.8%) received transfusions. No significant independent
increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio [OR], 0.90;
95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in
patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history
of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a
surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen
users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of
the 95% CI suggests the difference could be nearly 10 times greater.

CONCLUSIONS AND RELEVANCE The risk for sPTH is not increased with use of postoperative
ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy
with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with
ibuprofen use when using transfusion rate as a surrogate marker for severity.

Author Affiliations: Author


affiliations are listed at the end of this
article.
Corresponding Author: Pamela A.
Mudd, MD, MBA, Division of Pediatric
Otolaryngology, Childrens National
Medical Center, 111 Michigan Ave NW,
JAMA Otolaryngol Head Neck Surg. 2017;143(7):712-717. doi:10.1001/jamaoto.2016.3839 Washington, DC 20010
Published online May 4, 2017. (pmudd@cnmc.org).

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Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage Original Investigation Research

T
onsillectomy is one of the most commonly performed
surgical procedures in children, with more than 500 000 Key Points
procedures performed each year in the United States.1
Question Is the severity of posttonsillectomy hemorrhage
Clinical practice guidelines have been established to provide evi- requiring surgical control correlated with ibuprofen use?
dence for high-quality perioperative care among patients un-
Findings In this retrospective cohort study of 8868 pediatric
dergoing tonsillectomy.2 Recommendations for corticosteroid
patients undergoing tonsillectomy, 222 (3.3%) required surgical
use, antibiotic use, and pain management are included. The
intervention for posttonsillectomy hemorrhage, with no
guidelines also recommend monitoring one of the common yet correlation between hemorrhage requiring surgical control and
serious outcomes of tonsillectomy, posttonsillectomy hemor- ibuprofen exposure. Fifteen children (0.2%) required transfusion;
rhage (PTH). Although many studies have evaluated the risk as- children using ibuprofen had an increased risk for transfusion
sociations of postoperative pain management and PTH, few when hemorrhage occurred.
studies have qualified the severity of PTH, with the exception Meaning Ibuprofen used in postoperative management of pain
of specifying the need for surgical control of PTH (sPTH).3,4 after tonsillectomy has not been shown to increase the overall risk
Ibuprofen is a nonsteroidal anti-inflammatory drug that acts for posttonsillectomy hemorrhage; the severity of bleeding is
by inhibiting cyclooxygenase and thereby inhibiting prosta- difficult to quantify but may be a more important outcome to
glandin synthesis. Prostaglandins are local mediators of fever, measure.
inflammation, and pain. As a nonselective cyclooxygenase in-
hibitor, ibuprofen additionally inhibits platelet aggregation and
increases bleeding time through inhibition of thromboxane A2.5 performed at an outside hospital and patients for whom the
Therefore, ibuprofen has the potential to increase postopera- EHR data were not accessible for validation were excluded. All
tive hemorrhage. Recent evidence, however, suggests that electronically derived data were deidentified. This study was
ibuprofen is not associated with an increased risk for PTH.6,7 The approved by the internal review board of CHOP, which quali-
most recent guidelines, published in 2011, support the use of fied the study as exempt from informed consent.
ibuprofen in postoperative pain management.2 Based on the lit- CHOP is a tertiary teaching childrens hospital with 13
erature and these guidelines, postoperative pain management pediatric otolaryngologyspecialized attending staff. Resi-
protocols were modified for children undergoing tonsillec- dent- and fellow-level trainees are involved in surgical cases.
tomy or adenotonsillectomy at Childrens Hospital of Philadel- The standard surgical method at CHOP is complete tonsillec-
phia (CHOP) by routinely prescribing ibuprofen beginning Janu- tomy using monopolar cautery. A single surgeon routinely used
ary 1, 2013. The standard prescribed dose of ibuprofen was coblation for tonsillectomy in 2012 and then began to use mo-
7 mg/kg administered every 6 hours in addition to a combina- nopolar cautery for tonsillectomy and coblation for adenoid-
tion of acetaminophen (10 mg/kg) and oxycodone hydrochlo- ectomy and tonsillar fossae hemostasis. Suture is not rou-
ride (0.075 mg/kg). In May 2014, the use of ibuprofen was tinely used for tonsillectomy or for treatment of PTH. Cases
stopped because of clinical observations suggesting that the could not be specifically examined for technique with our data
severity of PTH had increased, which may have had links to ibu- set, however; previous studies have not shown a significant dif-
profen use. Therefore, a retrospective review of all patients ference in PTH rates.8-10 Standard anesthetic regimen at CHOP
undergoing tonsillectomy before and after ibuprofen imple- includes sevoflurane induction with intermittent propofol and
mentation was performed to determine whether the clinical opioid (fentanyl citrate or morphine sulfate), or nondepolariz-
observation could be validated statistically. Emergency trans- ing muscle relaxants may be used as indicated throughout the
fusion, defined as a transfusion in the emergency department procedure. Dexamethasone sodium phosphate is routinely ad-
or during sPTH, was used as a surrogate of severity of PTH. ministered. Dexmedetomidine hydrochloride was introduced
in 2012 but was not used routinely during the study period. Most
readmissions for PTH are managed surgically at CHOP.
The initial cohort was identified from hospital billing
Methods records through querying for patient encounters with the afore-
The population of interest included patients undergoing ton- mentioned CPT codes. The sPTH group was identified by que-
sillectomy or adenotonsillectomy since implementation of the rying control of oropharyngeal hemorrhage requiring second-
inpatient electronic health record (EHR) at CHOP in 2011, al- ary surgical intervention (CPT code 42962). Each case was
lowing inclusion of approximately 2 years of patient data be- specifically queried for age, preoperative diagnosis, and use
fore and 2 years after ibuprofen was included as part of stan- of ibuprofen in postoperative pain management. Patients were
dard postoperative pain control protocols. This retrospective assigned to the ibuprofen exposure group if they received ibu-
cohort study included patients from January 1, 2011, through profen before discharge from the hospital or if they were given
June 30, 2014. The patients were identified in the EHR (Epic an ibuprofen prescription for use after discharge. Patients who
Systems Corporation). Inclusion criteria consisted of all required secondary sPTH underwent screening for blood trans-
patients undergoing tonsillectomy (Current Procedural fusions occurring in the 30-day period after tonsillectomy using
Terminology [CPT] code 42825/42826) or tonsillectomy and ad- an internal review boardapproved study on evaluation of cur-
enoidectomy (CPT code 42820/42821) at all surgical facilities rent surgical blood order practice at CHOP. The postoperative
(1 main operating room and 3 ambulatory surgical centers). Pa- day of return for operative intervention indicated for PTH was
tients who underwent sPTH after the primary procedure was also recorded.

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Research Original Investigation Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage

Table 1. Demographic Characteristics of Multivariate Analysisa


Patients Patients With sPTH, No. (%)
Total Without sPTH,
Clinical Characteristic No. No. (%) All Early (24 h) Late (>24 h) Transfusion
Full cohort 6710 6488 (96.7) 222 (3.3) 34 (0.5) 188 (2.8) 15 (0.2)
Ibuprofen exposure 2122 2060 (97.1) 62 (2.9) 9 (0.4) 53 (2.5) 8 (0.4)
No ibuprofen exposure 4588 4428 (96.5) 160 (3.5) 25 (0.5) 135 (2.9) 7 (0.2)
Age, y
<12 6012 5841 (97.2) 171 (2.8) 30 (0.5) 141 (2.3) 14 (0.2)
12 698 647 (92.7) 51 (7.3) 4 (0.6) 47 (6.7) 1 (0.1)
Preoperative diagnosis
OSA/SDB 5520 5361 (97.1) 159 (2.9) 30 (0.5) 129 (2.3) 12 (0.2)
Tonsillitis 1190 1127 (94.7) 63 (5.3) 4 (0.3) 59 (5.0) 3 (0.3)
a
Abbreviations: OSA/SDB, obstructive sleep apnea/sleep-disordered breathing; In multivariate analysis, a second sPTH in the same patient was not recounted.
sPTH, surgically managed posttonsillectomy hemorrhage. Percentages have been rounded and may not sum to totals.

Multivariate analysis was completed for patients who had fusions, and (3) the blood bank database (Meditech) to iden-
complete information available in the clinical data ware- tify all patients receiving blood products within 30 days after
house, including age (younger than 12 years vs 12 years or older tonsillectomy or adenotonsillectomy. Data were validated using
based on surgical CPT code that recognizes a difference be- randomly selected medical records for manual review from an
tween these age groups), preoperative diagnosis (sleep- existing quality improvement database. The primary focus of
disordered breathing and/or obstructive sleep apnea [SDB/ the data review was to identify the frequency of patients re-
OSA] vs tonsillitis), and whether an ibuprofen prescription was quiring sPTH. A surrogate for severity was explored through
issued (yes or no). The preoperative diagnosis was retrieved capturing transfusion requirements in volume per body mass
from the surgical procedure notes via text mining. The surgi- (milliliters per kilogram). A manual review of all patients who
cal procedure notes used standard text descriptions that were received transfusion in the postoperative period was com-
mapped to SDB/OSA or tonsillitis. The EHR problem list was pleted for further validation.
queried with International Classification of Diseases, Ninth The data query was unable to identify patients who
Revision (ICD-9) codes 474.0 to 474.9 for tonsillar disease. presented with PTH and did not require sPTH. The primary out-
Manual review of the preoperative assessment at the ear, nose, come of this study was to determine the correlation of
and throat clinic was performed for patients with PTH who did severity of sPTH with ibuprofen exposure.
not have a preoperative diagnosis available for database ex-
traction and for patients with other chronic diseases of the ton-
sils and adenoids (ICD-9 code 474.8) or unspecified chronic dis-
eases of tonsils and adenoids (ICD-9 code 474.9).
Results
Multivariate logistic regression analysis was applied to the We identified 8868 patients as having undergone tonsillectomy
dependent variables sPTH and sPTH with transfusion, with the (or adenotonsillectomy) from January 20, 2011, through June
following independent variables: (1) age categorized as younger 30, 2014. A total of 6710 patients (3454 male [51.5%] and 3256
than 12 years or 12 years or older, (2) preoperative diagnosis female [48.5%]; median age, 5.4 years [interquartile range, 3.7-
categorized as OSA (inclusive of SDB and obstructive tonsillar 8.2 years]) met inclusion criteria for analysis. Two hundred
hypertrophy with or without adenoid hypertrophy) and re- thirty-five medical records (3.5%) required manual validation.
current tonsillitis (including a subgroup of patients with SDB/ All 6710 patients, including all 222 patients presenting with sPTH
OSA and recurrent tonsillitis [<2%]), and (3) ibuprofen expo- (3.3%), were included in the multivariate analysis (Table 1). None
sure categorized as yes or no. Additional variables described of the 2158 patients excluded from the study experienced the
included the timing of occurrence of sPTH as early (post- sPTH outcome. The mean and mode for age were 6.5 and 3.4
operative day 0-1 [24 hours]) vs late (postoperative day 2 or years. Most of the patients were younger than 12 years.
longer [>24 hours]), administration of blood transfusion within Twenty patients (0.3%) during the 4-year study period pre-
30 days after adenotonsillectomy, and the number of pa- sented with subsequent recurrence of sPTH after initial sPTH.
tients requiring more than 1 sPTH. Statistical analysis was con- This group consisted of 7 patients exposed to ibuprofen and 13
ducted with STATA software (version 13; StataCorp) using mul- not exposed to ibuprofen. Two patients in this group received
tivariate logistic regression. transfusions, both of whom were younger than 12 years and were
Databases queried included (1) the EHR (Epic Systems in the ibuprofen exposure group. For both patients, the trans-
Corporation) to identify all patients undergoing tonsillec- fusion was received during the second sPTH procedure.
tomy or adenotonsillectomy as well as sPTH and to extract The cumulative 4-year rate of sPTH in our multivariate co-
medications administered in the hospital and prescriptions at hort was 3.3%, with 20 patients (0.3%) requiring more than 1
discharge, (2) the anesthesia information management sys- surgical exploration for hemorrhage control. Fifteen patients
tem (CompuRecord; Philips) to identify intraoperative trans- (0.2%) required transfusion. A total of 2122 patients (31.6%)

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Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage Original Investigation Research

were exposed to ibuprofen, which was primarily confined to


Table 2. Multivariate Analysis for sPTHa
the years 2013 and 2014 after implementation of new postop-
erative tonsillectomy pain management protocols. Among the sPTH Variable Adjusted OR (95% CI)
2122 patients with ibuprofen exposure, 62 (2.9%) had sPTH Age 12 y 2.74 (1.99-3.76)

compared with 160 of 4588 (3.5%) not exposed to ibuprofen. Preoperative diagnosis of tonsillitis 1.52 (1.12-2.06)
Ibuprofen exposure was not associated with sPTH (adjusted Ibuprofen exposure 0.90 (0.68-1.19)
odds ratio [OR], 0.90; 95% CI, 0.68-1.19). Both age 12 years or Abbreviations: OR, odds ratio; sPTH, surgically managed posttonsillectomy
older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and preoperative hemorrhage.
a
diagnosis of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12- Includes 6710 patients.
2.06) were independently associated with sPTH (Table 2).
Transfusion associated with secondary surgical interven-
Table 3. Allogeneic Blood Product Transfusion
tion was used as a marker for increased severity of hemor- Within 30 Days of Tonsillectomya
rhage. All patients requiring transfusion after tonsillectomy or
Transfusion Variable Adjusted OR (95% CI)
adenotonsillectomy required sPTH. Of all patients undergoing
Age 12 y 0.28 (0.035-2.28)
tonsillectomy (or adenotonsillectomy), 15 (0.2%) received a
Preoperative diagnosis of tonsillitis 1.02 (0.26-3.99)
transfusion, including 8 patients in the ibuprofen exposure
Ibuprofen exposure 3.16 (1.01-9.91)
group. Of the 222 patients undergoing sPTH, 15 underwent trans-
fusion for a cumulative 4-year transfusion rate of 6.8%. The sPTH Abbreviation: OR, odds ratio.
a
group consisted of 62 patients exposed to ibuprofen with 8 trans- Includes 222 patients. One patient received a transfusion for preoperative
fusions (12.9%) and 160 patients not exposed to ibuprofen with anemia related to sickle cell disease and did not require intervention for
posttonsillectomy hemorrhage.
7 transfusions (4.4%) for an absolute difference of 8.5% (95%
CI, 0.1%-19.3%). Logistic regression analysis of sPTH with trans-
fusion did not find association with age (adjusted OR, 0.28; 95% were unsuccessful owing to the lack of standardization of when
CI, 0.04-2.28) or preprocedure diagnosis (adjusted OR, 1.02; the hemoglobin and hematocrit results were obtained in as-
95% CI, 0.26-3.99). Ibuprofen exposure was associated with a sociation with timing of hemorrhage and because this infor-
3-fold higher risk for transfusion during sPTH (adjusted OR, 3.16; mation was recorded in multiple portions of the EHR at dif-
95% CI, 1.01-9.91), suggesting a significant association of ibu- ferent times. In most cases, the hemorrhage starts when
profen with more severe bleeding, with the upper limit of the patients are outside the hospital and swallow blood, making
95% CI suggesting that the increased severity risk could be nearly it difficult to quantify the blood volume lost during this pe-
10 times greater (Table 3). riod. Therefore, in our study, transfusion rate was used as a
marker of severity in sPTH. We found a statistically signifi-
cant and clinically meaningful increased rate of transfusion
with sPTH among patients with ibuprofen exposure. The 95%
Discussion CI is very wide owing to the small number of outcome events
Ibuprofen use has become more acceptable and widespread (only 15 patients required transfusion). This 95% CI suggests
in controlling postoperative pain in patients who have had ton- that the association of ibuprofen with more severe bleeding
sillectomy, likely relating to the recently published American that requires transfusion could be anywhere from a 1-fold to a
Academy of OtolaryngologyHead and Neck Surgery Founda- nearly 10-fold increase (the upper limit of the 95% CI is 9.91).
tion clinical practice guidelines, which include reviews of criti- A larger study is needed to generate a more precise estimate
cal papers suggesting that the hemorrhage rate is not elevated.2 of effect. We found no association between patient age and pre-
The most recent prospective randomized trial comparing the operative diagnosis of tonsillitis and ibuprofen use.
use of ibuprofen with narcotic-based postoperative pain man- Few previous studies have evaluated transfusion risk in
agement in patients after tonsillectomy found no increased risk PTH. In a small study examining the risk for transfusion in 100
for hemorrhage with ibuprofen. However, a significant in- patients undergoing tonsillectomy during a 9-year period,12 the
crease in postoperative hypoxemia was seen in patients re- rate of hemorrhage was 6% and the rate of transfusion was 3%.
ceiving opioids.11 Conclusions from the study question the im- Two of the 3 patients receiving a transfusion in that cohort had
plication of using opioids at all in children aged 1 to 10 years abnormal coagulation profiles. A postoperative pain manage-
because the risk outweighs the benefit of ibuprofen and acet- ment protocol was not mentioned in that study. Children with
aminophen, which have consistently been shown to have von Willebrand disease or hemophilia face an increased risk
equivalent analgesia rates. Although analgesia was not exam- for PTH, with a rate of 15% reported in a UK study13 that in-
ined in this study, we have shown that rate of sPTH is not sig- cluded 500 high-risk patients. The rate of transfusion in that
nificantly increased with use of ibuprofen. group was 2.4%, but the effect of postoperative pain manage-
Few studies have evaluated the severity of sPTH as a di- ment protocols was not mentioned.
rect function of ibuprofen use likely in part because determin- In the literature, the reported rate of transfusion after PTH
ing whether the quantity of blood loss relates to the hemor- is low and is consistent with the findings in our large cohort. This
rhage severity or the timing of presentation to the emergency study is the first, to our knowledge, to examine transfusion risk
department is difficult. Attempts to examine trends in hemo- as a surrogate for severity of sPTH in a large cohort. The asso-
globin level nadir or cumulative change in hematocrit level ciation of ibuprofen implementation and rate of transfusion is

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Research Original Investigation Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage

important to consider in counseling patients and may have spe- tabases nor the temporal association with ibuprofen use and
cific implications in resuscitation management protocols for pa- the time of hemorrhage. Including only those patients who re-
tients with severe PTH. Furthermore, transfusion rates in PTH quire sPTH limits the ability to make conclusions regarding all
require monitoring and reporting to determine whether the readmissions for PTH. The data retrieval techniques used limit
widespread increase in the severity of PTH is in fact associated our ability to examine patients individually to understand in-
with ibuprofen use. Last, ibuprofen dose standardization has dications and variation in techniques. Posttonsillectomy hem-
not been examined to determine the minimal threshold for orrhage is likely to be a multifactorial problem, and account-
optimal analgesia or the dose-dependent risk of PTH. ing for all variables that contribute to it may be difficult.
Querying clinical data sets such as this one may pose addi-
Limitations tional challenges because often data are not recorded consis-
The nature of the study using database acquisition relies on cor- tently in the same way over time.14 Future efforts to study pa-
rect data entry. Furthermore, changes in postoperative pain tient outcomes will benefit from ongoing standardization of
management by a parent or outside clinician may have added EHR at a national level and can build on frameworks, such as
ibuprofen, which cannot be captured and would lead to some the one described in this study, when evaluating large patient
patients in the nonexposure group having had exposure to ibu- populations.
profen and therefore a possible crossover effect that cannot be
captured with our data set. Platelet function usually returns to
normal within 12 hours after administration of ibuprofen,5 and
the relative timing of the last dose of ibuprofen in association
Conclusions
with the timing of hemorrhage cannot be captured and may be Tonsillectomy is one of the most common surgical proce-
relevant. In addition, standardization in dosing regimen can- dures performed in children. Monitoring critical outcomes of
not be clarified and thus may also weaken the conclusion of this tonsillectomy aims to improve the quality of surgical care. Ad-
study. Based on these limitations, we believe it is prudent to con- ditional investigations of postoperative pain management pro-
sider standardized dosing and administration of ibuprofen with tocols that optimize analgesia while achieving the maximal
prospective follow-up of outcomes that include rates of trans- safety profile are ongoing. Ibuprofen is now widely used in
fusion. Finally, standardized documentation of readmission postoperative management of patients undergoing tonsillec-
characteristics of patients with PTH can aid in understanding tomy. The risk for PTH was not increased overall with the post-
of the true effect of ibuprofen on sPTH and clinical course, spe- operative use of ibuprofen; however, a statistically signifi-
cifically 24-hour medication reconciliation at the time of read- cant and clinically meaningful independent increased risk was
mission and clear documentation regarding bleeding history, in found among ibuprofen users 12 years or older who had pre-
addition to routine preresuscitation and postresuscitation operative diagnosis of recurrent tonsillitis. In addition, this co-
hematocrit and hemoglobin levels. hort is, to our knowledge, the first and largest to specifically
Given that the severity of PTH is difficult to quantify and examine transfusion rates in sPTH as a surrogate marker for
the incidence of the most severe complications is very small, severity. The data suggest a statistically significant and clini-
our field must continue to evaluate these complications in cally meaningful increase in the use of transfusion products
multi-institutional outcome registries at regional or national among ibuprofen users. Additional studies are warranted to
levels. The PTH rate is low, and the rate of transfusion even investigate this association before any definitive conclusions
lower; thus, to demonstrate definitely whether an associa- can be made regarding the potential risk for severe hemor-
tion exists between ibuprofen and severe sPTH, a much larger rhage with routine prescription of nonsteroidal anti-
patient sample would be required. inflammatory medications for posttonsillectomy analgesia.
Multiple assumptions are made in this study. Patients who Prospective monitoring of hemorrhage inclusive of the sever-
received a prescription for ibuprofen were considered as ex- ity of hemorrhage and the rates of transfusion should be con-
posed to the medication. We cannot determine how many sidered for ongoing and future outcomes-based projects for
times the medication was administered from the existing da- adenotonsillectomy.

ARTICLE INFORMATION Pennsylvania, Philadelphia (Thottathil, Glvez); Pennsylvania (Ahumada, Glvez); Department of
Accepted for Publication: January 28, 2017. Division of Otolaryngology (Ear, Nose, and Throat), Biomedical and Health Informatics, Childrens
Childrens Hospital of Philadelphia, Philadelphia, Hospital of Philadelphia, Philadelphia, Pennsylvania
Published Online: May 4, 2017. Pennsylvania (Giordano, Wetmore, Elden); (Glvez).
doi:10.1001/jamaoto.2016.3839 Department of OtorhinolaryngologyHead and Author Contributions: Drs Jawad and Ahumada
Author Affiliations: School of Medicine and Health Neck Surgery, Childrens Hospital of Philadelphia, had access to data for purposes of database and
Sciences, George Washington University, Philadelphia, Pennsylvania (Wetmore, Elden); statistical analysis, respectively. Drs Mudd and
Washington, DC (Mudd); Division of Pediatric Department of Biostatistics in Pediatrics, Perelman Glvez had full access to all the data in the study
Otolaryngology, Childrens National Medical Center, School of Medicine, University of Pennsylvania, and take responsibility for the integrity of the data
Washington, DC (Mudd); Department of Philadelphia (Jawad); Enterprise Reporting and and the accuracy of the data analysis.
Anesthesiology and Critical Care Medicine, Analytics, Childrens Hospital of Philadelphia, Study concept and design: Mudd, Wetmore, Jawad,
Childrens Hospital of Philadelphia, Philadelphia, Philadelphia, Pennsylvania (Ahumada); Section of Glvez.
Pennsylvania (Thottathil, Glvez); Department of Biomedical Informatics, Department of Acquisition, analysis, or interpretation of data: All
Anesthesiology and Critical Care Medicine, Anesthesiology and Critical Care Medicine, authors.
Perelman School of Medicine, University of Childrens Hospital of Philadelphia, Philadelphia,

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Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage Original Investigation Research

Drafting of the manuscript: Mudd, Wetmore, 2. Baugh RF, Archer SM, Mitchell RB, et al; tonsillectomy: a meta-analysis of randomized
Glvez. American Academy of OtolaryngologyHead and controlled trials. Arch Otolaryngol Head Neck Surg.
Critical revision of the manuscript for important Neck Surgery Foundation. Clinical practice 2011;137(6):558-570.
intellectual content: All authors. guideline: tonsillectomy in children. Otolaryngol 9. Burton MJ, Doree C. Coblation versus other
Statistical analysis: Thottathil, Jawad, Ahumada, Head Neck Surg. 2011;144(1)(suppl):S1-S30. surgical techniques for tonsillectomy. Cochrane
Glvez. 3. Windfuhr J, Seehafer M. Classification of Database Syst Rev. 2007;(3):CD004619.
Administrative, technical, or material support: haemorrhage following tonsillectomy. J Laryngol Otol.
Glvez. 10. Glade RS, Pearson SE, Zalzal GH, Choi SS.
2001;115(6):457-461. Coblation adenotonsillectomy: an improvement
Study supervision: Wetmore, Elden, Glvez.
4. Achar P, Sharma RK, De S, Donne AJ. Does over electrocautery technique? Otolaryngol Head
Conflict of Interest Disclosures: All authors have primary indication for tonsillectomy influence Neck Surg. 2006;134(5):852-855.
completed and submitted the ICMJE Form for post-tonsillectomy haemorrhage rates in children?
Disclosure of Potential Conflicts of Interest and 11. Mahant S, Keren R, Localio R, et al; Pediatric
Int J Pediatr Otorhinolaryngol. 2015;79(2):246-250. Research in Inpatient Settings (PRIS) Network.
none were reported.
5. Schafer AI. Effects of nonsteroidal Variation in quality of tonsillectomy perioperative
Meeting Presentation: This paper was presented antiinflammatory drugs on platelet function and care and revisit rates in childrens hospitals. Pediatrics.
at the Annual Meeting of the American Society of systemic hemostasis. J Clin Pharmacol. 1995;35(3): 2014;133(2):280-288.
Pediatric Otolaryngology; April 25, 2015; Boston, 209-219.
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