New probability tool could help reduce bleeding rates in children undergoing tonsillectomy

The findings of the retrospective cohort study, published in JAMA Otolaryngology–Head & Neck Surgery, provided estimated bleeding rates to guide surgeons in self-monitoring their frequency and improving quality outcomes for pediatric patients following tonsillectomy.

This study involving 96 415 children who underwent tonsillectomy found that the predicted 5th, 50th, and 95th quantiles for bleeding after a tonsillectomy procedure were 1.17%, 1.97%, and 4.75%, respectively.

An updated guideline issued in 2019 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation for pediatric tonsillectomies recommended that surgeons self-monitor the bleeding rates of their patients after these procedures. The lead author on those guidelines was Ron Mitchell, University of Texas Southwestern Medical Center at Dallas, also the current study's lead author.

Complications after tonsillectomies are rare, but excessive bleeding is considered the most common factor in the very few deaths related to the surgery. The authors note that the change in guidelines is a significant step towards improving tonsillectomy safety, but a significant hurdle was their effective use. According to them, no standards existed to inform doctors whether their institutional or personal bleeding rates were considered low, normal, or high.

Against the above background, Romaine F. Johnson from the University of Texas Southwestern Medical Center at Dallas and colleagues aimed to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring this event using a national cohort of children.

They collected data from the Pediatric Health Information System database of the Children's Hospital Association, which contains de-identified patient information covering outpatient surgeries, inpatient stays, observation unit patient data, and emergency department visits from more than 49 not-for-profit children's hospitals in the US.

The investigators were primarily focused on data comprising patients who came to the emergency department (ED) or were readmitted for bleeding following tonsillectomies, indicating that their bleeding after the procedure was considered excessive. They collected medical histories and demographic data on these patients.

The authors reported the following findings:

• Of the 96 415 children (mean age, 5.3 years; 42.8% female) who had undergone tonsillectomy, 2.18% returned to the ED or hospital with postoperative bleeding.
• The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively.
• Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19), very high residential Opportunity Index (OR, 1.28), gastrointestinal disease (OR, 1.33), obstructive sleep apnea (OR, 0.85), obesity (OR,1.24), and being more than 12 years old (OR, 2.48).
• The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%.

"Our findings provide estimated bleeding rates to guide surgeons in self-monitoring their frequency and improving quality outcomes for pediatric patients after tonsillectomy," the research team concluded.

Reference:

Johnson RF, Beams DR, Zaniletti I, et al. Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy: A Retrospective National Cohort Study of US Children. JAMA Otolaryngol Head Neck Surg. Published online March 30, 2023. doi:10.1001/jamaoto.2023.0268