Menu
Search BMJ Group Search BMJ Group Journals Jobs Education Decision support Quality improvement Community BMJ Group
From trainee to consultant, BMJ Group offers doctors around the world tailored information, special events, learning resources and recruitment services at every step along their career path.
... by doctors, for doctors, for patients About BMJ Group Customer Service Subscriptions & Sales Working for BMJ Group BMJ Media Centre BMJ Group Awards Advertising & Sponsorship Rights & Licensing Affinity & Society Publishing Online learning BMJ Learning High-quality CME / CPD for doctors and other healthcare professionals. BMJ Learning features hundreds of accredited, peer-reviewed learning modules in text, video, and audio formats. Find out more Courses and Qualifications BMJ Masterclasses BMJ Masterclasses, led by experts, help clinicians to use the latest evidence and recent guidelines in practice and meet their CPD/CME requirements. Find out more Exam Preparation 
The leading provider of online exam preparation, helping over 167,000 healthcare professionals to pass their exams. Find out more BMJ Learning BMJ Portfolio BMJ Masterclasses Clinical Leadership Programme Diabetes Qualifications and Courses onExamination Decision support and clinical reference BMJ Evidence Centre The BMJ Evidence Centre builds evidence into practice, to support improvements in the consistency and quality of health care.
Best Practice Clinical Evidence Evidence Updates Best Health Action Sets
Informatica Systems Informatica Systems delivers performance management systems and innovative software solutions to primary care. Learn more Audit + Contract + Health Checks FrontDesk BMJ Quality 
The latest news, research, events, opinion and guidance related to quality and safety in health care.
The 2013 event will take place in London from 16th- 19th April 2013. Find out more BMJ Quality BMJ Quality and Safety International Forum on Quality and Safety in Healthcare BMJ The flagship general medical journal, published since 1840, updated daily online, weekly in print and on the iPad.
BMJBMJ Journals BMJ Journals division publishes over 40 journals across a broad range of specialties.
BMJ JournalsstudentBMJ An international medical journal written for students by students.
Student BMJ JobsBMJ Careers BMJ Careers makes it easy for you to find the right job with the latest healthcare vacancies, upcoming careers fairs, advice on choosing the right specialty, pay and working conditions.
19-20 October 2012 at the Business Design Centre in Islington, London. Register here BMJ Careers Jobs and vacancies at BMJ Group BMJ Careers Fair Community 
Join the discussions on our community site doc2doc or our social pages
... by doctors, for doctors, for patientsWe are open for entries! doc2doc Follow BMJ Group on Twitter BMJ Group on Facebook BMJ Group Awards Subscribe My account
Update my details
Manage my emails
BMA Members Sign in Username: * Password: * Forgot your sign in details?BMA membersAthens or your organisation BMJ Helping doctors make better decisions Search bmj.com: Advanced search Home Research Education News Comment Multimedia Specialties Archive Search all BMJ research articles: From18401841184218431844184518461847184818491850185118521853185418551856185718581859186018611862186318641865186618671868186918701871187218731874187518761877187818791880188118821883188418851886188718881889189018911892189318941895189618971898189919001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012JanFebMarAprMayJunJulAugSepOctNovDec To18401841184218431844184518461847184818491850185118521853185418551856185718581859186018611862186318641865186618671868186918701871187218731874187518761877187818791880188118821883188418851886188718881889189018911892189318941895189618971898189919001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012JanFebMarAprMayJunJulAugSepOctNovDec Limit by AllResearchMethods and reporting Our online table of contents is updated at least twice each day. Read all articles published in the last 7 days. You can use bmj.com to help you with your continuing medical education. Find out about CME/CPD credits for BMJ articles Keep up to date with cardiology: Access the latest cardiovascular medicine resources from across BMJ Group.OPEN ACCESS: All research articles are freely available online, with no word limit. Find out more about the BMJ's open access policy. Submit your paper. Find out how study types differ in our How to read a paper section. The truth about sports drinks: Find out more about the joint BMJ and BBC Panorama investigation into the evidence base behind many health claims. Research Effect of systemic steroids on post-tonsillectomy bleeding and reinterventions: systematic review and meta-analysis of randomised controlled trials BMJ 2012; 345 doi: 10.1136/bmj.e5389 (Published 28 August 2012) Cite this as: BMJ 2012;345:e5389 Clinical trials (epidemiology) Ear, nose and throat/otolaryngology Otolaryngology / ENT Epidemiologic studies More topics Haematology (incl blood transfusion) Internet Fewer topics Article Related content Read responses (1) Article metrics Jennifer Plante, fellow1, Alexis F Turgeon, assistant professor12, Ryan Zarychanski, assistant professor34, François Lauzier, assistant professor125, Louise Vigneault, lecturer1, Lynne Moore, assistant professor26, Amélie Boutin, research assistant2, Dean A Fergusson, associate professor71Department of Anesthesiology, Division of Critical Care Medicine, Université Laval, Centre Hospitalier Affilié Universitaire de Québec (CHA), Enfant-Jésus Hospital, Québec City, QC, Canada, G1J 1Z42CHA Research Center (Enfant-Jésus Hospital), Trauma-Emergency-Critical Care Medicine Unit, Université Laval3Department of Hematology and Medical Oncology, CancerCare Manitoba, Winnipeg, MB, Canada4Departments of Internal Medicine and of Community Health Sciences, University of Manitoba, Winnipeg5Department de Medicine, Université Laval6Department of Social and Preventive Medicine, Université Laval7Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, CanadaCorrespondence to: A F Turgeon alexis.turgeon{at}fmed.ulaval.caAccepted 25 July 2012AbstractObjective To evaluate the risk of postoperative bleeding and reintervention with the use of systemic steroids in patients undergoing tonsillectomy.Design Systematic review and meta-analysis of randomised controlled trials.Data sources Medline, Embase, Cochrane Library, Scopus, Web of Science, Intute, Biosis, OpenSIGLE, National Technical Information Service, and Google Scholar were searched. References from reviews identified in the search and from included studies were scanned.Review methods Randomised controlled trials comparing the administration of systemic steroids during tonsillectomy with any other comparator were eligible. Primary outcome was postoperative bleeding. Secondary outcomes were the rate of admission for a bleeding episode, reintervention for a bleeding episode, blood transfusion, and mortality.Results Of 1387 citations identified, 29 randomised controlled trials (n=2674) met all eligibility criteria. Seven studies presented a low risk of bias, but none was specifically designed to systematically identify postoperative bleeding. Administration of systemic steroids did not significantly increase the incidence of post-tonsillectomy bleeding (29 studies, n=2674 patients, odds ratio 0.96 (95% confidence interval 0.66 to 1.40), I²=0%). We observed a significant increase in the incidence of operative reinterventions for bleeding episodes in patients who received systemic steroids (12, n=1178, 2.27 (1.03 to 4.99), I²=0%). No deaths were reported. Sensitivity analyses were consistent with the findings.Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy, their use is associated with a raised incidence of operative reinterventions for bleeding episodes, which may be related to increased severity of bleeding events. Systemic steroids should be used with caution, and the risks and benefits weighed, for the prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their condition of use.IntroductionTonsillectomy with or without adenoidectomy is one of the most commonly performed ear, nose, and throat surgeries worldwide.1 2 After this intervention, many patients have nausea, vomiting, and pain.3 4 Without prophylaxis, the reported incidence of postoperative vomiting in children undergoing tonsillectomy ranges from 40% to 73%.5 6 7 8 Systemic steroids have been shown to be as efficient as 5-HT3 antagonists and droperidol in reducing postoperative nausea and vomiting.8 Their use is increasing and currently recommended in recent guidelines of the American Academy of Otolaryngology-Head and Neck Surgery Foundation for tonsillectomy in children.9 10 Furthermore, some studies suggest that steroids could be associated with an earlier return to a regular diet after tonsillectomy.2 11A recent randomised controlled trial comparing different doses of dexamethasone for preventing postoperative nausea and vomiting after tonsillectomy showed an increased incidence of postoperative bleeding and reoperation due to bleeding in the steroid group.12 Previous observational studies have also reported this association.13 14 A recent meta-analysis on dexamethasone and tonsillectomy bleeding found no increased risk of postoperative bleeding with the use of steroids.15 However, this review was not exhaustive and did not evaluate clinically significant outcomes such as operative reinterventions.Considering the frequent use and potential harm of systemic steroids to prevent postoperative nausea and vomiting after tonsillectomy, and the existence of effective alternatives such as 5-HT3 antagonists,10 we conducted a systematic review of randomised controlled trials to evaluate the risk of postoperative bleeding and of operative reinterventions after systemic steroids use in patients undergoing tonsillectomy.MethodsDesign and search strategyWe conducted a systematic review and meta-analysis of randomised controlled trials. A search strategy was developed for Medline (OVID, 1950-March 2011), Embase (OVID, 1947-March 2011), and the Cochrane Central Register of Controlled Trials (up to March 2011) (web appendix). We identified randomised controlled trials by incorporating validated filters for Medline16 and Embase.17 We also did a similar search of Scopus, the Web of Science, and Intute databases, as well as OpenSIGLE, Google Scholar, and the National Technical Information Service databases for the grey literature. Relevant abstracts and conference proceedings were identified using the Biosis database. References of pertinent reviews identified in the search were scanned to identify potentially relevant trials. Two reviewers (JP, LV) independently screened all studies for eligibility by titles and abstracts, and by full text publications if needed. A third reviewer (AFT) was consulted in instances when consensus could not be reached between the two reviewers. At the end of this selection process, Google Scholar was used to identify authors that cited any of the included studies. Additional studies identified by this method were then considered for eligibility.Study eligibilityAll randomised controlled trials of tonsillectomy (any indications) that compared the administration of any systemic steroids to any comparator (other intervention, placebo, or no intervention) were included, provided that bleeding or the absence of bleeding episodes (of any severity) were also reported or could be obtained from authors. We excluded studies including patients with bleeding disorders, patients on chronic steroid therapy, or patients in whom steroids were locally injected or sprayed on the tonsillar bed. Eligibility was not restricted by language, type of publication (for example, abstracts or full publications), or patients’ age. The primary outcome was the incidence of postoperative bleeding from the tonsillar fossa (any type of bleeding and of any severity). The secondary outcomes were the incidence of admission for bleeding episodes, operative reinterventions for bleeding episodes, red blood cells transfusion, and mortality. We defined an operative reintervention for a bleeding episode as any surgical procedure performed in the operating room or in the emergency department to stop bleeding from the surgical site. Patients requiring a reintervention in the operating room were considered being admitted to hospital after the procedure, and were included in the meta-analysis of admissions for bleeding episodes.Data abstractionWe developed a data abstraction form to standardise the data collection process, which was pilot tested on a landmark publication.12 For comparison purposes, all steroid doses were converted in dexamethasone equivalents. We converted fixed doses to mg/kg using the mean weight, when the data were provided. If weight was not provided, we used a standard weight of 60 kg for women and 70 kg for men in adults, and weight charts for children to estimate whether the mean dose was lower or greater than 0.5 mg/kg. Bleeding events that occurred on postoperative day zero, or within the first 24 hours, were considered as primary bleeding episodes. Episodes beyond that period of time were defined as secondary bleeding episodes. We contacted the corresponding authors of included studies if data were missing for bleeding episodes, admission, reintervention, red blood cells transfusion, or mortality, or if the methods required clarification. Two reviewers (JP, LV) performed the data collection process independently, and a third reviewer (AFT) resolved any discrepancies. A translator was consulted for studies published in languages other than English or French.Risk of bias assessmentThe risk of bias was assessed independently by two reviewers (JP, LV) using the Cochrane Collaboration’s risk of bias tool.16 Since the objective of the current review was to identify bleeding complications occurring in the acute and subacute perioperative period, studies with considerable numbers of patients lost to follow-up, as well as those with a short follow-up period (<24 h) were considered to have an increased risk of bias because of their potential for missed bleeding events.16 For this reason, we assigned an “unclear” overall risk of bias to studies with a proportion of lost to follow-up greater than 10% (incomplete outcome data).Data synthesisData were analysed using Cochrane Review Manager version 5.0 (Cochrane Collaboration) and summarised using Peto fixed effects models, appropriate for meta-analysis of rare events.18 We applied a continuity correction of 0.5 to studies reporting no event in both groups. All data were dichotomous, and associations were presented using odds ratio with 95% confidence intervals. An odds ratio greater than 1 implies greater risk in the steroid group, and an odds ratio less than 1 implies greater risk in the control group. We assessed the presence of heterogeneity using the I² statistic, which estimates the percentage of variation between study results that is due to heterogeneity rather than sampling error.19 We did sensitivity analyses, based on clinical (adults v children, cold or combined v hot dissection, high [>0.5 mg/kg] v low [=0.5 mg/kg] dose steroids, non-steroidal anti-inflammatory drug administration, type of comparator, and timing of bleeding) and methodological (risk of bias, blinding, sample size, and short [=24 h] v long [>24 h] follow-up) characteristics, to understand potential sources of heterogeneity and to evaluate the robustness of the results. Potential publication bias was assessed using funnel plot analyses.20Quality of evidenceWe graded the quality of evidence for the three main outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach 21 with GRADEpro software (version 3.2 for Windows. Jan Brozek, Andrew Oxman, Holger Schünemann, 2008).ResultsSearch resultsWe retrieved a total of 1387 citations (fig 1?). Fifty one studies were considered potentially eligible. Of these studies, 16 were excluded because they did not report bleeding episodes nor admission or reintervention, and this information could not be obtained despite attempts to contact the authors. The remaining excluded publications did not meet all inclusion criteria.22 23 24 25 26 27 We included 29 studies in this systematic review,12 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 representing 2674 patients (table 1?).
View larger version:In a new windowDownload as PowerPoint SlideFig 1 Flow diagram of studiesView this table:View PopupView InlineTable 1 Characteristics of included studies in meta-analysisStudy characteristicsOf the included studies, 24 were published in English, and one each in Turkish,34 Korean,39 Spanish,54 Chinese,29 and Hebrew.38 Ten studies were conducted in North America,30 31 32 33 35 40 47 53 54 55 12 in Asia,28 29 34 37 38 39 41 45 46 49 50 51 four in Europe,12 42 43 52 two in Australia,36 48 and one in Africa.44 All studies were presented as full publications. In two studies, dexamethasone was provided by pharmaceutical companies,12 32 and one of these studies specified that the funding organisation had no role in the design or conduct of the study.12Nineteen studies were performed in children, six in adults only, and four included both children and adults. Twenty four studies compared the effects of systemic steroids with placebo12 28 29 30 31 32 33 34 35 37 40 41 43 46 47 48 50 51 53 54 55 or no intervention (neither a placebo nor any intervention in the control group).38 39 45 Six studies compared systemic steroids with other treatments (tropisetron, ondansetron, droperidol, piroxicam, bilateral glossopharyngeal nerve block with bupivacaine, or paracetamol).Dexamethasone was used in 28 studies, while prednisolone was administered in the remaining study.48 In 18 studies, the dexamethasone dose was calculated according to the patient’s weight (mg/kg) and varied from 0.05 mg/kg 12 to 1.0 mg/kg. In the remaining studies, the steroid dose was fixed29 31 40 42 43 50 52 55; based on the patient’s body surface (mg/m²)32; or either fixed or based on weight (mg/kg), according to patient’s age.48 49 Systemic steroids were administrated as a single dose, or repeated doses over a specific period of time: 16 h,54 three days,40 four days,29 seven days,48 or eight days.52 In these studies, the total dose was taken into account.In most studies, the main outcomes were the effect of steroids on pain,12 28 29 30 31 32 33 35 37 38 39 40 41 42 43 44 45 47 48 50 51 52 53 54 55 nausea and vomiting,12 28 30 33 34 35 36 37 38 39 41 43 45 46 47 48 49 50 51 52 53 and oral intake 12 28 30 32 35 37 38 39 41 43 45 46 47 48 50 51 53 55 after tonsillectomy. Other main outcome measures of included studies were the effect of steroids on oedema, fever, trismus, halitosis, and level of activity.Twenty six studies reported data for post-tonsillectomy bleeding. Through private communications with authors, we obtained details pertaining to the severity of and to interventions related to the bleeding episodes for three of these studies,40 42 53 and obtained unpublished data on bleeding episodes for three additional studies.43 44 49 Eight studies reported no postoperative bleeding episodes or mentioned uneventful surgeries.29 37 43 44 48 49 51 54 Among studies reporting bleeding episodes, 18 specified the timing of occurrence,12 28 30 31 32 33 34 35 36 39 41 42 45 46 47 50 52 53 nine reported the need for admission due to bleeding,12 28 30 31 35 46 47 50 53 and 12 reported data for reintervention.12 30 32 34 39 40 42 46 47 50 52 55 No study reported transfusion of red blood cells or mortality.A clear definition of post-tonsillectomy bleeding was presented in two of 29 studies.12 42 Eight studies stated that bleeding episodes were going to be reported,12 28 31 32 33 35 37 41 while six clearly questioned their patients about postoperative bleeding or provided instructions in the event of unexpected bleeding.12 28 35 37 41 42 No study described a systematic method to evaluate postoperative bleeding.Validity assessmentA low risk of bias was attributed to seven studies 33 35 36 40 41 42 50 (table 2?). Fifteen studies had an adequate sequence generation,12 30 31 33 35 36 37 40 41 42 43 50 51 52 54 and 15 had an appropriate method of allocation concealment.12 30 33 35 36 40 41 42 43 47 48 50 52 53 55 Six studies were not blinded,28 38 39 45 46 49 and blinding was unclear in another study.34 One study was terminated early because of an increased incidence of post-tonsillectomy bleeding in the intervention group.12 Fourteen studies 12 31 32 33 36 38 40 41 42 43 47 52 53 55 reported losses to follow-up that varied from 2.7%12 to 36.1%,43 and losses to follow-up were unclear in four studies.29 39 45 48 Eight studies had a follow-up period of 24 h or less.30 34 37 44 45 46 49 51 Two studies reported performing an intention to treat analysis.12 40 Five studies did not report all outcomes stated in their methods.32 45 46 51 54View this table:View PopupView InlineTable 2 Risk of bias and methodological quality assessment of included studiesPost-tonsillectomy bleeding episodesThe administration of steroids did not increase the incidence of bleeding events after tonsillectomy, based on pooled data from the 29 studies (n=2674, odds ratio 0.96, 95% confidence intervals 0.66 to 1.40, I²=0%), of which eight did not observe any bleeding episodes29 37 43 44 48 49 51 54 (fig 2?). Sensitivity analyses including trials with low risk of bias, observers blinded to the intervention, larger population, or longer follow-up periods yielded similar results (table 3?). Results were also comparable regardless of the population age, surgical technique, steroid dose, or concomitant administration of non-steroidal anti-inflammatory drugs. When we analysed primary and secondary bleeding events separately, we observed no increase in bleeding incident with the administration of steroids.
View larger version:In a new windowDownload as PowerPoint SlideFig 2 Post-tonsillectomy bleeding. For Peto odds ratio, continuity correction k=0.5 was used when there was no event in both groupsView this table:View PopupView InlineTable 3 Sensitivity analysis of post-tonsillectomy bleeding outcomeHospital admissionSeventeen studies reported data for admission12 28 30 31 35 46 47 50 53 or reinterventions34 36 39 40 42 45 52 55 that required admission (fig 3?). The incidence of admission due to a bleeding episode did not increase in the steroid group (17 studies, n=1722 patients, odds ratio 1.16, 95% confidence interval 0.68 to 2.00, I²=19%). All sensitivity analyses accorded with this finding (data not shown).
View larger version:In a new windowDownload as PowerPoint SlideFig 3 Admission for post-tonsillectomy bleedingReintervention for a bleeding episodeThe incidence of operative reintervention for bleeding episodes was significantly increased in the steroid group (12 studies, n=1178; odds ratio 2.27, 95% confidence interval 1.03 to 4.99, I2=0%; fig 4?). The average incidence of reintervention due to bleeding in patients receiving steroids was 3.0% versus 1.5% in controls. Sensitivity analyses were performed to evaluate the incidence of reintervention for bleeding episodes among different subgroups (table 4?). We observed a significant increase of reinterventions in children (eight studies12 30 32 34 39 46 47 55; 3.43, 1.29 to 9.13, I²=0%) but not in adults (four40 42 50 52; 1.07, 0.29 to 4.03, I²=0%). A dose effect was not observed. We found an increased incidence of reinterventions among patients receiving non-steroidal anti-inflammatory drugs (three12 39 52; 4.10, 0.99 to 16.97, I²=0%). No significant association was seen among double blinded studies (nine12 30 32 40 42 47 50 52 55; 2.22, 0.95 to 5.18, I2=0%) and those with longer follow-up periods (nine12 32 39 40 42 47 50 52 55; 2.16, 0.92 to 5.06, I2=0%). In each case, the incidence of reinterventions for bleeding episodes was increased in the steroid group compared with the control group without reaching significance (P=0.07 for double blinding, P=0.08 for longer follow-up periods), although the results suggested a strong trend. Studies with low risk of bias showed no clear association between steroids use and the incidence of operative reintervention (three studies40 42 50; 0.91, 0.22 to 3.68, I²=0%).
View larger version:In a new windowDownload as PowerPoint SlideFig 4 Reintervention for post-tonsillectomy bleeding. For Peto odds ratio, continuity correction k=0.5 was used when there was no event in both groupsView this table:View PopupView InlineTable 4 Sensitivity analysis of operative reintervention to treat post-tonsillectomy bleedingAllogenic transfusion and mortalityNone of the included studies reported transfusion of red blood cells or mortality. Publication bias and quality of evidence We evaluated the presence of potential publication bias using a funnel plot of intervention effect estimates versus the standard error for studies presenting data for bleeding episodes. Visual inspection of the funnel plot did not reveal evidence of publication bias (web figure). According to the GRADE methodology, the quality of the evidence for bleeding and admission outcomes after tonsillectomy was low; however, the association between post-tonsillectomy reintervention and systemic steroids was considered to be of high quality (table 5?).View this table:View PopupView InlineTable 5 Summary of evidence for key outcomes Discussion In this systematic review, we did not observe an increased incidence of postoperative bleeding events after perioperative administration of systemic steroids in patients undergoing tonsillectomy. However, we did observe a significant increase in the incidence of operative reinterventions needed to manage clinically significant bleeding episodes in patients who received systemic steroids. The quality of the evidence according to the GRADE approach was high for this specific outcome. This raised incidence of reinterventions was significantly increased in children.Strengths and limitations if the studyAn important limitation of our study concerned the data available within included publications. None of the included studies was designed to evaluate adverse complications of steroids use after tonsillectomy, and no study systematically screened for bleeding events after tonsillectomy. Therefore, the incidence of this complication could have been systematically underestimated. Moreover, only two studies presented a clear definition of post-tonsillectomy bleeding. Bleeding episodes of varying severity may not have received equal consideration across all studies, which could lead to an underestimation of overall bleeding episodes. This could explain why we did not observe a significant association between steroids use and bleeding events, while we did observe an association with reintervention for bleeding events. On the other hand, the inclusion in meta-analyses of studies reporting no bleeding event in either group using a continuity correction could have underestimated the association. The majority of included studies were of limited methodological quality, and many studies had substantial numbers of patients who were lost to follow-up. These factors provide further concern that bleeding episodes may have been missed. A significant proportion of studies had a very limited follow-up period precluding the evaluation of the incidence of secondary bleeding episodes. Since bleeding episodes are relatively rare events, unreported episodes could greatly affect the study results. Despite of known limitations, our systematic review had important strengths. Firstly, the extensive search strategy using different databases, including the grey literature and conference proceedings, allowed us to retrieve a comprehensive list of the studies performed on the topic. Importantly, the decision to evaluate the incidence of reinterventions for bleeding episodes, as opposed to only bleeding episodes, allowed us to summarise the effect of clinically significant bleeding events with greater fidelity. We believe that operative reintervention for bleeding episodes represents a more reliable and clinically meaningful endpoint than bleeding episodes. Severe enough bleeding events to require operative reintervention are less likely to have been overlooked and may therefore represent the optimal clinical outcome to understand the impact of systemic steroids in tonsillectomy.Comparison with other studiesOverall, the mean incidence of post-tonsillectomy bleeding events observed in our systematic review was 4.4%, which is consistent with the current literature.56 57 58 59 60 Our results on postoperative bleeding are in accordance with a recent systematic review.15 However, this previous meta-analysis identified half the number of studies as compared with our study, and did not evaluate other clinically significant outcomes such as operative reinterventions for bleeding and hospital admission. The increased incidence of reintervention observed in a recent landmark study by Czarnetzki and colleagues12 was also seen in our pooled analysis. But our systematic review did not confirm the higher incidence of bleeding episodes associated with perioperative steroids use in tonsillectomy procedures, as observed in this trial.The increased incidence of reinterventions associated with steroids occurred in the absence of increased bleeding events, and thus probably represents an increased severity of bleeding when steroids are administered. Although no study specified indications to undergo a reintervention in the event of bleeding, this procedure usually suggests that the bleeding was significant enough to require an emergency procedure. Bleeding events requiring reintervention are more likely to be noticed and reported in a publication as opposed to minor events. Therefore, reinterventions to manage bleeding events may be a more objective and reliable outcome to assess clinically significant bleeding events after tonsillectomy.Conclusions and policy implicationsWe did not observe an increased incidence of postoperative bleeding events following administration of systemic steroids during tonsillectomy. We did, however, observe a significant increase in the incidence of operative reintervention associated with the use of steroids, which may be related to an increased severity of a given bleeding episode. Considering the potential for harm and the availability of other drugs to prevent postoperative nausea and vomiting, we recommend that steroids should be used with caution; risks and benefits must be weighted; and steroids should not be used routinely for such purposes, especially in children. Further studies should be designed to answer concerns about the safety of the perioperative use of steroids in tonsillectomy procedures.What is already known on this topicTonsillectomy is one of the most commonly performed ear, nose, and throat surgeries worldwide, but has a high underlying risk of postoperative nausea and vomitingSystemic use of steroids to reduce postoperative nausea and vomiting is increasing, and recommended in addition to the use of 5-HT3 antagonists in recent guidelinesA recent study has linked such use of steroids with an increased incidence of postoperative bleeding after tonsillectomyWhat this study addsOverall, the risk of postoperative bleeding did not increase after perioperative administration of systemic steroids in patients undergoing tonsillectomyHowever, the incidence of reinterventions for bleeding episodes did increase overall with steroids, and especially among children, which could represent a greater severity of bleeding associated with use of steroids Systemic steroids should be used with caution; risks and benefits must be weighted, and steroids should not be used routinely to prevent postoperative nausea and vomiting after tonsillectomy, especially in childrenNotesCite this as: BMJ 2012;345:e5389FootnotesWe thank Lucie Côté from the Library of the Centre Hospitalier Affilié Universitaire de Québec, Enfant-Jésus Hospital, for her help with the retrieval of study publications.Contributors: JP, AFT, RZ, FL, LM, and DAF contributed to the conception and design of the study. JP and LV determined eligibility of search results and extracted data from included studies. JP, AB, and AFT performed and reviewed the analyses, and drafted the manuscript. All authors participated in the interpretation of the data and the critical review of the manuscript, and approved the version to be published. AFT is the guarantor.Funding: This study was funded by personal funds. AFT and FL are recipients of a research career award from the Fonds de Recherche Québec-Santé. AFT and FL are supported by the Traumatology Research Consortium of the Fonds de Recherche Québec-Santé. LM and DAF are recipients of New Investigator Awards from the Canadian Institutes for Health Research. RZ is a recipient of a randomised controlled trials mentorship award from the Canadian Institutes for Health Research.Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.Ethical approval: This study did not require ethical approval.Data sharing: No additional data available.This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.References?Bolton CM, Myles PS, Nolan T, Sterne JA. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis. Br J Anaesth2006;97:593-604.OpenUrlFREE Full Text?Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev2011:CD003997.?Randall DA, Hoffer ME. Complications of tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg1998;118:61-8.OpenUrlFREE Full Text?Johnson LB, Elluru RG, Myer CM 3rd. Complications of adenotonsillectomy. Laryngoscope2002;112:35-6.OpenUrlMedlineWeb of Science?Litman RS, Wu CL, Catanzaro FA. Ondansetron decreases emesis after tonsillectomy in children. Anesth Analg1994;78:478-81.OpenUrlFREE Full Text?Furst SR, Rodarte A. Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy. Anesthesiology1994;81:799-803.OpenUrlMedlineWeb of Science?Ferrari LR, Donlon JV. Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesth Analg1992;75:351-4.OpenUrlFREE Full Text?Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med2004;350:2441-51.OpenUrlCrossRefMedlineWeb of Science?Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, et al. Clinical Practice Guideline. Otolaryngol Head Neck Surg2011;144:S1-30.OpenUrlFREE Full Text?Gan TJ, Meyer TA, Apfel CC, Chung F, Davis PJ, Habib AS, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg2007;105:1615-28.OpenUrlFREE Full Text?Goldman AC, Govindaraj S, Rosenfeld RM. A meta-analysis of dexamethasone use with tonsillectomy. Otolaryngol Head Neck Surg2000;123:682-6.OpenUrlFREE Full Text?Czarnetzki C, Elia N, Lysakowski C, Dumont L, Landis BN, Giger R, et al. Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a randomized trial. JAMA2008;300:2621-30.OpenUrlCrossRefMedlineWeb of Science?Collison PJ, Mettler B. Factors associated with post-tonsillectomy hemorrhage. Ear Nose Throat J2000;79:640-2.OpenUrlMedline?Macassey EA, Baguley C, Dawes P, Gray A. 15-year audit of post-tonsillectomy haemorrhage at Dunedin Hospital. ANZ J Surg2007;77:579-82.OpenUrlCrossRefMedlineWeb of Science?Geva A, Brigger MT. Dexamethasone and Tonsillectomy Bleeding. Otolaryngol Head Neck Surg2011;144:838-43.OpenUrlFREE Full Text?Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions, version 5.1.0. Cochrane Collaboration, 2011. www.cochrane-handbook.org.?Wong SS, Wilczynski NL, Haynes RB. Developing optimal search strategies for detecting clinically sound treatment studies in EMBASE. J Med Libr Assoc2006;94:41-7.OpenUrlMedlineWeb of Science?Yusuf S PR, Lewis J, Collins R, Sleight P Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis1985;27:335-71.OpenUrlMedlineWeb of Science?Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ2003;327:557-60.OpenUrlFREE Full Text?Ioannidis JP, Trikalinos TA. The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey. CMAJ2007;176:1091-6.OpenUrlFREE Full Text?Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ2004;328:1490.OpenUrlFREE Full Text?Fujii Y, Tanaka H, Toyooka H. Granisetron and dexamethasone provide more improved prevention of postoperative emesis than granisetron alone in children. Can J Anaesth1996;43:1229-32.OpenUrlMedlineWeb of Science?Gunter JB, McAuliffe JJ, Beckman EC, Wittkugel EP, Spaeth JP, Varughese AM. A factorial study of ondansetron, metoclopramide, and dexamethasone for emesis prophylaxis after adenotonsillectomy in children. Paediatr Anaesth2006;16:1153-65.OpenUrlMedline?Liechti M, Feurer R, Gross D, Schmitz A, Stutz K, Gerber A, et al. Prevention of postoperative nausea and vomiting in children following adenotonsillectomy, using tropisetron with or without low-dose dexamethasone. J Anesth2007;21:311-6.OpenUrlCrossRefMedlineWeb of Science?McAuliffe JJ, Gunter JB, Beckman EC. Dose-response relationship of dexamethasone and recovery after tonsillectomy in children [abstract 1228]. American Society of Anesthesiologists Annual Meeting; 2001 October. New Orleans, Anesthesiology, 2001.?McAuliffe JJ, Gunter JB, Beckman EC. A factorial study of ondansetron, metoclopramide, and dexamethasone for the prevention of emesis after tonsillectomy in children: model development [abstract 1225]. American Society of Anesthesiologists Annual Meeting; 2001 October. New Orleans, Anesthesiology, 2001.?Inci N, Basut O, Kasapoglu F, Coskun H. Management of pain after tonsillectomy: a prospective, randomized clinical study. Kulak Burun Bogaz Ihtis Derg2009;19:1-8.OpenUrlMedline?Alajmi MA, Al Noumas HS, Al-Abdulhadi KA, Kavitha G. Steroids for reducing post-tonsillectomy morbidity. Kuwait Med J2008;40:211-5.OpenUrlWeb of Science?Ammar G, Wang Z. Effect of dexamethasone on post tonsillectomy pain. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi2009;23:936-8.OpenUrlMedline?April MM, Callan ND, Nowak DM, Hausdorff MA. The effect of intravenous dexamethasone in pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg1996;122:117-20.OpenUrlCrossRefMedlineWeb of Science?Carr MM, Williams JG, Carmichael L, Nasser JG. Effect of steroids on posttonsillectomy pain in adults. Arch Otolaryngol Head Neck Surg1999;125:1361-4.OpenUrlMedlineWeb of Science?Catlin FI, Grimes WJ. The effect of steroid therapy on recovery from tonsillectomy in children. Arch Otolaryngol Head Neck Surg1991;117:649-52.OpenUrlCrossRefMedlineWeb of Science?Giannoni C, White S, Enneking FK. Does dexamethasone with preemptive analgesia improve pediatric tonsillectomy pain? Otolaryngol Head Neck Surg2002;126:307-15.OpenUrlFREE Full Text?Güne Y, Ünlügenç H, Gündüz M, Tuncer Ü, Akman H. [Comparison of the effects of ondansetron, dexamethasone and droperidol on the nausea and vomiting after tonsillectomy in children]. Çukurova Üniv T p Fak Derg2002;27:13-9.OpenUrl?Hanasono MM, Lalakea ML, Mikulec AA, Shepard KG, Wellis V, Messner AH. Perioperative steroids in tonsillectomy using electrocautery and sharp dissection techniques. Arch Otolaryngol Head Neck Surg2004;130:917-21.OpenUrlCrossRefMedlineWeb of Science?Holt R, Rask P, Coulthard KP, Sinclair M, Roberts G, Van Der Walt J, et al. Tropisetron plus dexamethasone is more effective than tropisetron alone for the prevention of postoperative nausea and vomiting in children undergoing tonsillectomy. Paediatr Anaesth2000;10:181-8.OpenUrlCrossRefMedlineWeb of Science?Kaan MN, Odabasi O, Gezer E, Daldal A. The effect of preoperative dexamethasone on early oral intake, vomiting and pain after tonsillectomy. Int J Pediatr Otorhinolaryngol2006;70:73-9.OpenUrlCrossRefMedlineWeb of Science?Kaufmann M, Deutsch E, Hamouri H. The effect of steroid therapy on post adenotonsillectomy recovery. Harefuah2006;145:577-80.OpenUrlMedline?Kim M, Lee J, Lee S, Baik S, Chang B. The Effect of Dexamethasone in Tonsillectomy. Korean J Otolaryngol Head Neck Surg1998;41:783-7.OpenUrl?Lachance M, Lacroix Y, Audet N, Savard P, Thuot F. The use of dexamethasone to reduce pain after tonsillectomy in adults: a double-blind prospective randomized trial. Laryngoscope2008;118:232-6.OpenUrlCrossRefMedlineWeb of Science?Malde A, Sonawane V, Jagtap S. Effect of dexamethasone on post tonsillectomy morbidities. Indian J Anaesth2005;49:202-7.OpenUrl?Mathiesen O, Jorgensen DG, Hilsted KL, Trolle W, Stjernholm P, Christiansen H, et al. Pregabalin and dexamethasone improves post-operative pain treatment after tonsillectomy. Acta Anaesthesiol Scand2011;55:297-305.OpenUrlCrossRefMedlineWeb of Science?McKean S, Kochilas X, Kelleher R, Dockery M. Use of intravenous steroids at induction of anaesthesia for adult tonsillectomy to reduce post-operative nausea and vomiting and pain: a double-blind randomized controlled trial. Clin Otolaryngol2006;31:36-40.OpenUrlCrossRefMedline?Mohamed SK, Ibraheem AS, Abdelraheem MG. Preoperative intravenous dexamethasone combined with glossopharyngeal nerve block: role in pediatric postoperative analgesia following tonsillectomy. Eur Arch Otorhinolaryngol2009;266:1815-9.OpenUrlCrossRefMedline?Mohammad L, Ahmad R, Latoo M, Qazl S, Wanl A. Post-tonsilelectomy morbidity—do steroids help. Indian J Otolaryngol Head Neck Surg2006;58:141-3.OpenUrl?Nawasreh O, Fraihat A, Maaita J. The effect of preoperative intravenous dexamethasone in pediatric adenotonsillectomy. J Bahrain Med Soc2000;12:130-3.OpenUrl?Ohlms LA, Wilder RT, Weston B. Use of intraoperative corticosteroids in pediatric tonsillectomy. Arch Otolaryngol Head Neck Surg1995;121:737-42.OpenUrlCrossRefMedlineWeb of Science?Palme CE, Tomasevic P, Pohl DV. Evaluating the effects of oral prednisolone on recovery after tonsillectomy: a prospective, double-blind, randomized trial. Laryngoscope2000;110:2000-4.OpenUrlCrossRefMedlineWeb of Science?Rabbani MZ, Khan MNA, Qureshi R, Zubair M, Bin Pervez M. Does the added benefit of Ondansetron over Dexamethasone, to control post-operative nausea and vomiting, justify the added cost in patients undergoing tonsillectomy and adenotonsillectomy? J Pak Med Assoc2010;60:559-61.OpenUrlMedline?Rujirojindakul P, Atchariyasathian V, Uakrìtdathikran T, Boonyata N, Boonthida Saefung B. Effect of dexamethasone on postoperative pain after adult tonsillectomy. Thai J Anesthesiol2008;34:1-8.OpenUrl?Samarkandi AH, Shaikh MA, Ahmad RA, Alammar AY. Use of dexamethasone to reduce postoperative vomiting and pain after pediatric tonsillectomy procedures. Saudi Med J2004;25:1636-9.OpenUrlMedlineWeb of Science?Stewart R, Bill R, Ullah R, McConaghy P, Hall SJ. Dexamethasone reduces pain after tonsillectomy in adults. Clin Otolaryngol Allied Sci2002;27:321-6.OpenUrlCrossRefMedline?Tom LWC, Templeton JJ, Thompson ME, Marsh RR. Dexamethasone in adenotonsillectomy. Int J Pediatr Otorhinolaryngol1996;37:115-20.OpenUrlCrossRefMedlineWeb of Science?Trujillo M, Ramírez J, Fuentes S. Efecto de la administración de dexametasona intravenosa en pacientes pediátricos post operados de amigdalectomía com o sin adenoidectomía. An ORL Méx2005;50:61-4.OpenUrl?Volk MS, Martin P, Brodsky L, Stanievich JF, Ballou M. The effects of preoperative steroids on tonsillectomy patients. Otolaryngol Head Neck Surg1993;109:726-30.OpenUrlMedlineWeb of Science?O’Leary S, Vorrath J. Postoperative bleeding after diathermy and dissection tonsillectomy. Laryngoscope2005;115:591-4.OpenUrlCrossRefMedlineWeb of Science?Lee M, Montague M, Hussain S. Post-tonsillectomy hemorrhage: cold versus hot dissection. Otolaryngol Head Neck Surg2004;131:833-6.OpenUrlFREE Full Text?British Association of Otorhinolaryngologists—Head and Neck Surgeons Comparative Audit Group and the Clinical Effectiveness Unit of the Royal College of Surgeons of England. National prospective tonsillectomy audit. Royal College of Surgeons of England, 2005.?Raut V, Bhat N, Kinsella J, Toner J, Sinnathuray A, Stevenson M. Bipolar scissors versus cold dissection tonsillectomy: a prospective, randomized, multi-unit study. Laryngoscope2001;111:2178-82.OpenUrlCrossRefMedlineWeb of Science?Windfuhr JP, Chen YS. Incidence of post-tonsillectomy hemorrhage in children and adults: a study of 4,848 patients. Ear Nose Throat J2002;81:626-8.OpenUrlMedline Open access PDFEasy ReadData supplementRespond to this article Tweet Services Email to friendDownload to citation managerAdd article to BMJ portfolioRequest permission Email Alerts Email me when this article is citedEmail me when responses are postedEmail me when a correction is posted Citations Find similar articles in PubMedArticles by Jennifer PlanteArticles by Alexis F TurgeonArticles by Ryan ZarychanskiArticles by François LauzierArticles by Louise VigneaultArticles by Lynne MooreArticles by Amélie BoutinArticles by Dean A FergussonCiting articles via Web of ScienceCiting articles via Scopus Social bookmarking 
CiteULike
Connotea
Del.icio.us
Digg
Facebook
Mendeley
Reddit
Twitter
Stumbleupon Latest jobsUK jobsInternational jobsUK jobs UNIVERSITY OF CAMBRIDGE CLINICAL LECTURER DIABETES/ENDOCRINOLOGY OR METABOLIC MEDICINE (23 Aug 2012) Plymouth Hospitals NHS Trust British Antarctic Survey Medical Unit Medical Officers (20 Aug 2012) NHS HAMPSHIRE Consultant in Public Health (31 Aug 2012) NHS AYRSHIRE AND ARRAN SPECIALTY DOCTOR SEXUAL AND REPRODUCTIVE HEALTHCARE (31 Aug 2012) show me all jobs >> International jobs DOCTORS - ENJOY THE GREAT LIFESTYLE in Australia and New Zealand. SHO/ Registrar/ Consultant and GP openings. (6 Jul 2012) Clinical Head of Emergency Department, Hutt Hospital Lower Hutt, New Zealand Reference: 957 Hutt Valley DHB, New Zealand is recruiting for (31 Aug 2012) Trincay Medical Services requires consultants specialized in Obstetrics and Gynecology, Oncology, Plastic Surgery and Rheumatology (30 Aug 2012) Deakin University Australia Chair in Medicine (30 Aug 2012) show me all jobs >> Rapid responses Latest ResponsesMost responsesLatest Responses Re: The crisis in diabetes care in England Published 2 September 2012 Re: The QOF is bad for diabetes care. Published 2 September 2012 Re: NHS health checks and the QOF will make overtreatment even more common Published 2 September 2012 Intracutaneous injections of sterile water as treatment of renal colic Published 2 September 2012 Re: The crisis in diabetes care in England - People or cash cows Published 2 September 2012 more Most responses Bad medicine: private practice (14 responses) Published 15 August 2012
Diagnosis and management of cellulitis (11 responses)Published 7 August 2012
Unhappy pills (11 responses)Published 10 August 2012
We should not let families stop organ donation from their dead relatives (8 responses)Published 7 August 2012
A national early warning score for acutely ill patients (7 responses)Published 8 August 2012
more THIS WEEK'S POLLRead related article
See previous polls
Recent blogs and podcastsBlogsPodcastsBlogs Tiago Villaneuva: The health benefits of dancing (31 Aug 2012) Toby Pitts-Tucker: The Paralympic legacy and disability hate crime (31 Aug 2012) Vasiliy Vlassov: Psychiatry and political dissent in Russia (31 Aug 2012) Pritpal S Tamber: The Red Hand Gang of healthcare? (30 Aug 2012) John Pring: On the Paralympics, DLAs, and PIPs (30 Aug 2012) more >> Podcasts Bad for wealth, bad for health? (31 Aug 2012) Ecological public health (24 Aug 2012) Fighting the food giants (17 Aug 2012) Is the drug pipeline really drying up? (10 Aug 2012) Renal patient records (3 Aug 2012) more >> BMJ most popular Most sharedMost searchedMost shared Sample size calculations: should the emperor’s clothes be off the peg or made to measure? (334 views) Good reason to test for vitamin D deficiency (226 views) Big tits (221 views) The health and development of children born to older mothers in the United Kingdom: observational study using longitudinal cohort data (205 views) Big tits (196 views) Most searched Kathleen Hilditch guyatt France how to read a paper chronic liver disease Follow BMJ Ontwitter.com/bmj_latestfacebook.com/bmjdotcomyoutube.com/user/BMJmedia Content Links Last 7 daysResearchEducationNewsCommentArchiveBlogsVideoPrint Issue My Account Email alertsActivate subscription Resources AuthorsReviewersBMA membersReadersSubscribersAdvertisers and sponsorsMedia Information Contact usFeedback BMJ About usEditorial staffAdvisersPoliciesComplaintsPartnershipsSubmit your paper Explore BMJ About BMJ GroupJunior Doctors: Agents for ChangeOlympics portalStudent BMJdoc2docJunior Doctor PortalPandemic FluBMJ Group BMJ Group Privacy and Cookie Policy Website T & Cs Revenue Sources HighWire Press Feedback Help © 2012 BMJ Publishing Group Ltd window.fbAsyncInit = function() {FB.init({appId: '154318714596620', status: true, cookie: true,xfbml: true});};(function() {var e = document.createElement('script'); e.async = true;e.src = document.location.protocol + '//connect.facebook.net/en_US/all.js';document.getElementById('fb-root').appendChild(e);}());View the original article here
This post was made using the Auto Blogging Software from WebMagnates.org This line will not appear when posts are made after activating the software to full version.
