2017-18 HSC Section 3 Green Book

Despite being relatively underpowered compared to the pediatric data, the adult data show statistically sig- nificantly increased risk of post-tonsillectomy hemor- rhage with ketorolac use. This may reflect differences in indications for tonsillectomy in children compared to adults; tonsillectomy done for obstructive sleep apnea in children may carry less risk compared to the same pro- cedure done for tonsillitis in adults. Prior studies have suggested overall increased rate of post-tonsillectomy hemorrhage in adults and older children compared to young children. 17 It is possible that the same risk factors that predispose to post-tonsillectomy hemorrhage in gen- eral in older patients also predispose to additional risk associated with ketorolac use.

4. Judkins JH, Dray TG, Hubbell RN. Intraoperative ketorolac and posttonsil- lectomy bleeding. Arch Otolaryngol Head Neck Surg 1996;122:937–940. 5. Kuehn BM. FDA: no codeine after tonsillectomy for children. JAMA 2013; 309:1100. 6. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions . Version 5.1.0 (updated March 2011). The Cochrane Collab- oration, 2011. Available at: http://www.cochrane-handbook.org. Accessed September 1, 2013. 7. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. 8. Gallagher JE, Blauth J, Fornadley JA. Perioperative ketorolac trometh- amine and postoperative hemorrhage in cases of tonsillectomy and ade- noidectomy. Laryngoscope 1995;105:606–609. 9. Splinter WM, Rhine EJ, Roberts DW, Reid CW, Macneill HB. Preoperative ketorolac increases bleeding after tonsillectomy in children. Can J Anaesth 1996;43:560–563. 10. Agrawal A, Gerson CR, Seligman I, Dsida RM. Postoperative hemorrhage after tonsillectomy: use of ketorolac tromethamine. Otolaryngol Head Neck Surg 1999;120:335–339. 11. Gunter JB, Varughese AM, Harrington JF, et al. Recovery and complica- tions after tonsillectomy in children: a comparison of ketorolac and mor- phine. Anesth Analg 1996;81:1136–1141. 12. Keidan I, Zaslansky R, Eviatar E, Segal S, Sarfaty SM. Intraoperative ketorolac is an effective substitute for fentanyl in children undergoing outpatient adenotonsillectomy. Paediatr Anaesth 2004;14:318–323. 13. Romsing J, Ostergard D, Walther-Larsen S, Valentin N. Analgesic efficacy and safety of preoperative versus postoperative ketorolac in pediatric tonsillectomy. Acta Anaesthesiol Scand 1998;42:770–775. 14. Rusy LM, Houck CS, Sullivan LJ, et al. A double-blind evaluation of ketor- olac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding. Anesth Analg 1995;80:226–229. 15. Sutter KA, Levine JD, Dibble S, Savedra M, Miaskowski C. Analgesic effi- cacy and safety of single-dose intramuscular ketorolac for postoperative pain management in children following tonsillectomy. Pain 1995;61:145– 153. 16. Pinder DK, Wilson H, Hilton MP. Dissection versus diathermy for tonsil- lectomy. Cochrane Database Syst Rev 2011;3:CD002211. 17. Sarny S, Ossimitz G, Habemann W, Stammberger H. Hemorrhage follow- ing tonsil surgery: a multicenter prospective study. Laryngoscope 2011; 121:2553–2560.

CONCLUSION Ketorolac is associated with an increased risk of post-tonsillectomy hemorrhage in adults but not children.

BIBLIOGRAPHY 1. Bailey R, Sinha C, Burgess LP. Ketorolac tromethamine and hemorrhage in tonsillectomy: a prospective, randomized, double-blind study. Laryn- goscope 1997;107:166–169. 2. Cardwell ME, Siviter G, Smith AF. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Data- base of Syst Rev 2010;7:CD003591. 3. Baugh RF, Archer SM, Mitchell RB, et al.; American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 144:S1–S30.

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