This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (69) Citing Articles via Google Scholar Google Scholar Articles by Møiniche, S. Articles by Tramèr, M. R. Search for Related Content PubMed PubMed Citation Articles by Møiniche, S. Articles by Tramèr, M. R. Related Collections Surgery Postanesthetic Care Unit Pediatrics Pharmacology

---

PEDIATRIC ANESTHESIA

Nonsteroidal Antiinflammatory Drugs and the Risk of Operative Site Bleeding After Tonsillectomy: A Quantitative Systematic Review

Steen Møiniche, MD^*, Janne Rømsing, MS, Pharm, PhD, Jørgen B. Dahl, MD, DMSc^*, and Martin R. Tramèr, MD, DPhil

*Department of Anesthesiology and Intensive Care Medicine, Herlev University Hospital; Department of Pharmaceutics, The Royal Danish School of Pharmacy, Copenhagen, Denmark; and Division of Anesthesiology, Geneva University Hospitals, Switzerland

Address correspondence to Steen Møiniche, MD, Department of Anesthesiology and Intensive Care Medicine, Herlev University Hospital, DK-2730, Copenhagen, Denmark. Address e-mail to moiniche{at}dadlnet.dk

The use of nonsteroidal antiinflammatory drugs (NSAIDs) for analgesia after tonsillectomy is controversial because NSAIDS, through platelet inhibition, may increase the risk of perioperative bleeding. We systematically searched for randomized, controlled trials that reported on the incidence of perioperative bleeding attributable to the use of NSAIDs in patients undergoing tonsillectomy. As secondary outcome measures, we analyzed the quality of pain relief and the incidence of postoperative nausea and vomiting. Twenty-five studies with data from 970 patients receiving a NSAID and 883 receiving a non-NSAID treatment or a placebo were analyzed. Data were combined using a fixed-effect model. Of four bleeding end points (intraoperative blood loss, postoperative bleeding, hospital admission, and reoperation because of bleeding), only reoperation happened significantly more often with NSAIDs: Peto-odds ratio, 2.33 (95% confidence interval [CI], 1.12–4.83) and number-needed-to-treat, 60 (95% CI, 34–277). Compared with opioids, NSAIDs were equianalgesic, and the risk of emesis was significantly decreased (relative risk, 0.73; 95% CI, 0.63–0.85; numbers-needed-to-treat, 9; 95% CI, 5–19).

IMPLICATIONS: The evidence for nonsteroidal antiinflammatory drugs to increase the risk of bleeding after tonsillectomy is equivocal, and the risk-benefit ratio is not straightforward. There is some evidence for an increased likelihood of reoperation because of bleeding. The agenda must be one of further research rather than of clinical recommendations.

This article has been cited by other articles:

				C. Czarnetzki, N. Elia, C. Lysakowski, L. Dumont, B. N. Landis, R. Giger, P. Dulguerov, J. Desmeules, and M. R. Tramer Dexamethasone and Risk of Nausea and Vomiting and Postoperative Bleeding After Tonsillectomy in Children: A Randomized Trial JAMA, December 10, 2008; 300(22): 2621 - 2630. [Abstract] [Full Text] [PDF]

				T. Sun, O. Sacan, P. F. White, J. Coleman, R. J. Rohrich, and J. M. Kenkel Perioperative Versus Postoperative Celecoxib on Patient Outcomes After Major Plastic Surgery Procedures Anesth. Analg., March 1, 2008; 106(3): 950 - 958. [Abstract] [Full Text] [PDF]

				T. J. Gan, T. A. Meyer, C. C. Apfel, F. Chung, P. J. Davis, A. S. Habib, V. D. Hooper, A. L. Kovac, P. Kranke, P. Myles, et al. Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting Anesth. Analg., December 1, 2007; 105(6): 1615 - 1628. [Abstract] [Full Text] [PDF]

				Feedback CEACCP, October 1, 2007; 7(5): 177 - 178. [Full Text] [PDF]

				N S Morton Management of postoperative pain in children Arch. Dis. Child. Ed. Pract., February 1, 2007; 92(1): ep14 - ep19. [Full Text] [PDF]

				C. M. Bolton, P. S. Myles, T. Nolan, and J. A. Sterne Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis Br. J. Anaesth., November 1, 2006; 97(5): 593 - 604. [Abstract] [Full Text] [PDF]

				E. Munsterhjelm, T. T. Niemi, O. Ylikorkala, P. J. Neuvonen, and P. H. Rosenberg Influence on platelet aggregation of i.v. parecoxib and acetaminophen in healthy volunteers Br. J. Anaesth., August 1, 2006; 97(2): 226 - 231. [Abstract] [Full Text] [PDF]

				T. J. Gan Risk factors for postoperative nausea and vomiting. Anesth. Analg., June 1, 2006; 102(6): 1884 - 1898. [Abstract] [Full Text] [PDF]

				P. F. White The Changing Role of Non-Opioid Analgesic Techniques in the Management of Postoperative Pain Anesth. Analg., November 1, 2005; 101(5S_Suppl): S5 - 22. [Abstract] [Full Text] [PDF]

				I. Power Recent advances in postoperative pain therapy Br. J. Anaesth., July 1, 2005; 95(1): 43 - 51. [Full Text] [PDF]

				P.-A. Lonnqvist and N. S. Morton Postoperative analgesia in infants and children Br. J. Anaesth., July 1, 2005; 95(1): 59 - 68. [Full Text] [PDF]

				P. F. White Changing Role of COX-2 Inhibitors in the Perioperative Period: Is Parecoxib Really the Answer? Anesth. Analg., May 1, 2005; 100(5): 1306 - 1308. [Full Text] [PDF]

				C. K.-S. Ong, P. Lirk, R. A. Seymour, and B. J. Jenkins The Efficacy of Preemptive Analgesia for Acute Postoperative Pain Management: A Meta-Analysis Anesth. Analg., March 1, 2005; 100(3): 757 - 773. [Abstract] [Full Text] [PDF]

				S. Turner and V. Ford Role of the selective cyclo-oxygenase-2 (COX-2) inhibitors in children Arch. Dis. Child. Ed. Pract., October 1, 2004; 89(2): ep46 - ep49. [Full Text] [PDF]

				S R Desikan and N G Meena Do non-steroidal anti-inflammatory drugs increase the risk of bleeding after tonsillectomy? Arch. Dis. Child., May 1, 2004; 89(5): 493 - 494. [Full Text] [PDF]

				E. D. Kharasch Perioperative COX-2 Inhibitors: Knowledge and Challenges Anesth. Analg., January 1, 2004; 98(1): 1 - 3. [Full Text] [PDF]

				E. Munsterhjelm, T. T. Niemi, M. T. Syrjala, O. Ylikorkala, and P. H. Rosenberg Propacetamol augments inhibition of platelet function by diclofenac in volunteers Br. J. Anaesth., September 1, 2003; 91(3): 357 - 362. [Abstract] [Full Text] [PDF]

				P. J. S. Koo Acute Pain Management Journal of Pharmacy Practice, August 1, 2003; 16(4): 231 - 248. [Abstract] [PDF]

				T. J. Gan, T. Meyer, C. C. Apfel, F. Chung, P. J. Davis, S. Eubanks, A. Kovac, B. K. Philip, D. I. Sessler, J. Temo, et al. Consensus Guidelines for Managing Postoperative Nausea and Vomiting Anesth. Analg., July 1, 2003; 97(1): 62 - 71. [Abstract] [Full Text] [PDF]