Bleeding after tonsillectomy
- Meta-analysis
- Results
- Comment
Where
you live in the world, and what type of health service you have, will determine
whether you have tonsillectomy as a day case, or have a week in hospital. A
week in hospital used to be the norm, of course, and one reason for the stay
was the risk of a bleed after the operation. What determines the stay is when
bleeding occurs. A new meta-analysis provides an insight [1].
Meta-analysis
A
systematic review sought results of adult and paediatric tonsillectomy series
that provided both the numbers of bleeding events and when they occurred.
Adenoidectomies, and adenoid bleeds from adenotonsillectomies, were excluded.
Bleeding events were as defined by the original authors, so included more and
less serious bleeding events. The incidence of bleeding was then assessed
overall for the first eight hours after operation, between eight and 24 hours,
and after 24 hours.
Results
Sixteen
studies provided the required data, with 27,305 patients. Studies varied in
size from 94 to almost 7,000 patients. Seven included only day cases, and four
were a mix of day case and longer postoperative stays. All of the studies
provided information on bleeding during the first 24 hours, and 11 for periods
longer than 24 hours.
In
the first eight hours after operation there were 343 bleeds, a rate of 1.3%. In
the period between eight and 24 hours there were 32 bleeds, a rate of 0.12%.
There was a clear decay in the number of bleeds during the first 24 hours, with
most frequent occurrence in the first five hours, and with only sporadic
bleeding after eight hours. Beyond 24 hours there were 398 bleeds, a rate of
1.8% (Figure 1).
Figure 1: Incidence rates of bleeding after tonsillectomy by time after the operation
Comment
The
results of this analysis showed that most bleeding occurred early after
operation, or after 24 hours. This does not support an argument for a mandatory
overnight stay after tonsillectomy. It appears that 833 patients would need to
be kept in overnight to identify one case of bleeding after eight hours and
before next day discharge. There will always be good reasons why some patients
should have at least an overnight stay, and some of these are shown in Table 1.
Table 1: Exclusion criteria for day case tonsillectomy for individual patients where overnight stay may be more appropriate
|
Exclusion criteria for day case
tonsillectomy
|
| Medical problems |
| Severe asthma |
| Diabetes |
| Coagulation disorder |
| Hypersomnia/slees apnoea |
| Sickle cell disease |
| Epilepsy |
| Other conditions where overnight stay may
be required |
| Social reasons |
| No access to telephone |
| No access to car |
| Only one adult at home if other children
in house |
The
paper argues that with about 90,000 tonsillectomies a year, and with an
overnight bed costing about £300, the potential saving by moving from
complete overnight stays to complete day case surgery is of the order of
£20-30 million for the NHS in the UK if the beds were closed or used for
something else. There are also implications here about discharge before eight
hours.
An
interesting example, this, of how systematic review and meta-analysis can
impact directly on the design and purchasing of services. It goes to the heart
of what is appropriate in service design on the one hand, and what is best for
individual patients on the other. Good evidence trumps dogma every time.
Reference:
- 1 AM Bennett et al. Meta-analysis of the timing of haemorrhage after tonsillectomy: an important factor in determining the safety of performing tonsillectomy as a day case procedure. Clinical Otolaryngology 2005 30:418-423.
