Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol Vol: 3 Issue: 5

The Effect of Paracetamol, Metamizole Sodium and Ketoprofen on Postoperative Hemorrhage Following Pediatric Tonsillectomy

Duran Karataş*, Fatih Yüksel and Murat Doğan
Melikgazi Medical Center, Kayseri, Turkey
Corresponding author : Duran Karataş
Duran germir mh. konaklar cad, 423. sk.akda ÄŸ, Apt. No: 4/7, Turkey
E-mail: [email protected]
Received: June 13, 2014 Accepted: August 14, 2014 Published: September 15, 2014
Citation: Karataş D, Yüksel F, Doğan M (2014) The Effect of Paracetamol, Metamizole Sodium and Ketoprofen on Postoperative Hemorrhage Following Pediatric Tonsillectomy. J Otol Rhinol 3:5. doi:10.4172/2324-8785.1000181

Abstract

The Effect of Paracetamol, Metamizole Sodium and Ketoprofen on Postoperative Hemorrhage Following Pediatric Tonsillectomy

Aim: The aim of the present study was to determine the association between postoperative hemorrhage and using paracetamol, metamizole sodium and ketoprofen as analgesics after pediatric tonsillectomy.

Patients and Methods: 330 children with recurrent tonsillitis and/or obstructive symptoms were included in the present study. Children were divided into three groups based on the medicines used for postoperative pain. Each group was administered paracetamol, metamizole sodium or ketoprofen after the surgery. Study population was compared for postoperative hemorrhage. Chi-square test was used for statistical analysis.

Results: A total of 109 patients were administered ketoprofen while 110 patients received metamizole sodium and 111 patients received paracetamol. Post-tonsillectomy hemorrhage developed in 13 (3, 53) children among which there were three primary hemorrhage cases and one secondary hemorrhage case. Post-operative hemorrhage was observed in 5 (4, 36%) of the 109 cases receiving ketoprofen, in 4 (3, 64%) of the patients receiving metamizole sodium and in 4 (3, 57%) of the patients receiving paracetamol. There was no statistically significant difference with respect to hemorrhage rates among these three groups (p<0.05).

Conclusion: In our study, no significant increase was shown in hemorrhage risk after using ketoprofen, metamizole sodium and paracetamol, which suggests that these drugs can be used safely for post-tonsillectomy pain.

Keywords: Tonsillectomy; Hemorrhage; Ketoprofen; Metamizole sodium; Paracetamol

Keywords
Tonsillectomy; Hemorrhage; Ketoprofen; Metamizole sodium; Paracetamol

Introduction

Tonsillectomy is the most frequently performed operation by otolaryngologists. After tonsillectomy, a post-operative pain, which affects nutrition and quality of life, is frequently observed. Paracetamol is the most commonly used medicine for post-operative pain. An intense inflammatory reaction occurs at the operation area after the operation while hemorrhage is the most feared complication. Sometimes, paracetamol is not sufficient for pain control. The question is whether we can use nonsteroidal anti-inflammatory drugs safely. The aim of the present study was to determine the association between postoperative hemorrhage and paracetamol, metamizole sodium and ketoprofen administration.

Materials and Methods

A total of 330 children undergoing tonsillectomy and/or adenotonsillectomy for recurrent tonsillitis (chronic inflammation, 220 patients) and/or obstructive symptom (110 patients) between February 2010 and April 2013 were included in the study. After the operation, children were classified into 3 groups based on the medicines administered for pain. Paracetamol group 110 patient (64 chronic inflammation, 47 obstructive symptom), metamizol group 110 patient (58 chronic inflammation, 52 obstructive symptom), ketoprofen group 109 patient (61 chronic inflammation, 48 obstructive symptom).Each group was administered paracetamol, metamizol or ketoprofen for at least ten days after the surgery. The study group consisted of 134 females (average age 6, 4 ± 0, 7) and 166 males (average age 8, 3 ± 0, 1). Before the operation, it was checked whether the patients had bleeding diathesis. Total blood count, active partial thromboplastin time, prothrombin time and bleeding time were checked and found to be normal in all children before the operation. Operations were performed by the same surgeon. Tonsillectomy was carried out using thermal welding equipment while adenoidectomy was performed by adenotome. Bleeding control was achieved by a buffer in adenoid and by thermal welding in tonsillectomy while no other methods were employed. İntraoperative corticosteroids applied to patients.After the operation, children were followed-up for an average of six hours at the hospital and were discharged on the same day with dietary instructions. Patients were advised to visit the hospital urgently in case of bleeding and were followed-up for a one month term. Controls were performed on the 3rd, 7th, 15th and 30th days. And primary (occurring within 24 h of the operation) and secondary bleedings (occurring within 1–14 days) were determined. The study population was compared for post-operative hemorrhage. Chi-square test was used for statistical analysis.

Results

A total of 109 patients (34 females, 75 males, average age 5, 9 ± 0, 3) were administered ketoprofen while 110 patients (46 females, 64 males, average age 7, 2 ± 0, 4) received metamizole sodium and 111 patients (54 females, 57 males, average age 5, 3 ± 0, 7) received paracetamol. Post-tonsillectomy hemorrhage developed in 13(8 chronic inflammation, 5 obstructive symptom) (%3, 53) children among which there were 12 (7 chronic inflammation, 5 obstructive symptom) primary hemorrhage cases and one secondary hemorrhage case (chronic inflammation). Postoperative hemorrhage was observed in 5(3 chronic inflammation, 2 obstructive symptom) (4, 36%) of the 109 cases receiving ketoprofen, in 4 (3 chronic inflammation, 1 obstructive symptom) (3, 64%) of the patients receiving metamizole sodium and in 4 (2 chronic inflammation, 2 obstructive symptom) (3, 57%) of the patients receiving paracetamol. The case of secondary hemorrhage was ketoprofen. The patient had a history of hard and abrasive food intake. None of the patients needed a life-saving intervention. Thermal welding was used in controlling all bleedings. There was no statistically significant difference with respect to hemorrhage rates among these three groups (p<0.05).

Discussion

Tonsillectomy is the most frequently performed operation. Hemorrhage is the most feared complication. Factors defining predisposition to bleeding and increasing or decreasing its frequency have been studied both intra-operatively and post-operatively. Pain is the factor which affects post-operative quality of life the most. Reducing pain effectively would increase the quality of life too.
In tonsillectomy, the most common surgical indications are obstruction (49.7%), followed by recurrent tonsillitis (35.2%) [1]. In the present study, indications of tonsillectomy and adenoidectomy were the same and examinations were carried out before the operation. In a study where prothrombin time, activated partial thromboplastin time, international normalized ratio (INR), and platelet count were determined before tonsillectomy, it was found that those having a mildly elevated INR had a higher incidence of postoperative hemorrhage [2]. In another study, the relationship between preoperative clinical diagnosis and postoperative hemorrhage was studied and it was found that postoperative hemorrhage rate was lower in patients with obstructive sleep apnea when compared to those with chronic tonsillitis [3].
There have been intra-operative studies aiming to reduce hemorrhage after tonsillectomy. Closure of tonsillar fossa by suture after tonsillectomy does not decrease the risk of bleeding but increase postoperative pain [4]. Perioperative dexamethasone administration does not increase the risk of hemorrahage after pediatric tonsillectomy [5]. In a meta-analysis of 12 studies, the association between dexamethasone administration and postoperative hemorrhage was investigated and no significant association was found between dexamethasone and hemorrhage compared to placebo [6]. In a study analyzing factors associated with and prognostic for bleeding after tonsillectomy, it was found that hemorrhage after tonsillectomy was associated with the administration of steroids and with the nonadministration of non-steroidal anti-inflammatory drugs [7].
Likewise, post-operative actions do not affect hemorrhage. In a study, one of the groups received amoxicillin with clavulanic acid for 5 days in the post-operative period while the other group received nothing. It was observed that the use of antibiotics did not reduce post-operative morbidity and thus it was advised to use antibiotics on an individual basis rather that routinely [8]. In the present study, antibiotics were used post-operatively.
The method of operation employed affects hemorrhage too. There are many studies conducted on this subject [9-11]. In our study, tonsillectomy was performed by thermal welding while adenoidectomy was performed by adenotom.
In a review published in 2012, 233 complications were found from 1984 to 2010. Among the said complications, there were 96 deaths (41%) and 137 perioperative injuries (59%). 40% of the deaths were primarily related to hemorrhage [12]. Thus, hemorrhage is a complication that should be dealt with most seriously after tonsillectomy. In the present study, post-tonsillectomy hemorrhage developed in 13 (3, 53%) children among which there were three primary hemorrhage cases and one secondary hemorrhage case. Postoperative hemorrhage was observed in 5 (4, 36%) of the 109 cases receiving ketoprofen, in 4 (3, 64%) of the patients receiving metamizole sodium and in 4 (3, 57%) of the patients receiving paracetamol.
Post-operative pain in tonsillectomy affects morbidity a lot. Paracetamol is the most frequently used medicine. Fearing an increase in hemorrhage, non-steroid anti-inflammatory drugs are usually not administered. In a study, NSAID, opioid, 5-HT (3) receptor antagonist ve dexametasone were used and it was found that dexamethasone did not increase postoperative hemorrhage [13]. Several studies using ibuprofen reported that ibuprofen did not increase the risk of hemorrhage after tonsillectomy and thus could be used safely [14,15]. In our study, ketoprofen was used and found not to increase the risk of postoperative hemorrhage.

Conclusion

In our study, no significant increase was shown in hemorrhage risk after ketoprofen, metamizole sodium and paracetamol administration, which suggests that these can be used safely for pain control.

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