Research

JAMA OtolaryngologyHead & Neck Surgery | Original Investigation

Association Between Ibuprofen Use and Severity

of Surgically Managed Posttonsillectomy Hemorrhage
Pamela A. Mudd, MD, MBA; Princy Thottathil, MD; Terri Giordano, DNP, CRNP, CORLN; Ralph F. Wetmore, MD;
Lisa Elden, MD; Abbas F. Jawad, PhD; Luis Ahumada, PhD; Jorge A. Glvez, MD, MBI

Editorial page 649

IMPORTANCE Ibuprofen used in postoperative management of pain after tonsillectomy has Author Audio Interview
not been shown to increase the overall risk for posttonsillectomy hemorrhage (PTH). The
severity of bleeding is difficult to quantify but may be a more important outcome to measure.

OBJECTIVE To evaluate the association between ibuprofen use and severity of PTH using
transfusion events as a marker of severity.

DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study identified 8868
patients who underwent tonsillectomy from January 20, 2011, through June 30, 2014, at the
tertiary academic Childrens Hospital of Philadelphia. Of these patients, 6710 met the
inclusion criteria. Data were collected using electronic database acquisition and query.

MAIN OUTCOMES AND MEASURES Multivariate analysis was performed to identify

independent prognostic factors for PTH and receipt of transfusion.

RESULTS Of the 6710 patients who met criteria for analysis (3454 male [51.5%] and 3256
female [48.5%]; median age, 5.4 years [interquartile range, 3.7-8.2 years]), 222 (3.3%)
presented with PTH that required surgical control (sPTH). A total of 15 of the 8868 patients
required transfusion for an overall risk for transfusion after tonsillectomy of 0.2%. Fifteen of
222 patients undergoing sPTH (6.8%) received transfusions. No significant independent
increased risk for sPTH was associated with use of ibuprofen (adjusted odds ratio [OR], 0.90;
95% CI, 0.68-1.19). A significant independent association was found in the risk for sPTH in
patients 12 years or older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and in patients with a history
of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-2.06). When using transfusion rates as a
surrogate for severity of sPTH, transfusion increased by more than 3-fold among ibuprofen
users compared with nonusers (adjusted OR, 3.16; 95% CI, 1.01-9.91), and the upper limit of
the 95% CI suggests the difference could be nearly 10 times greater.

CONCLUSIONS AND RELEVANCE The risk for sPTH is not increased with use of postoperative
ibuprofen but is increased in patients 12 years or older and patients undergoing tonsillectomy
with a history of recurrent tonsillitis. Hemorrhage severity is significantly increased with
ibuprofen use when using transfusion rate as a surrogate marker for severity.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Pamela A.
Mudd, MD, MBA, Division of Pediatric
Otolaryngology, Childrens National
Medical Center, 111 Michigan Ave NW,
JAMA Otolaryngol Head Neck Surg. 2017;143(7):712-717. doi:10.1001/jamaoto.2016.3839 Washington, DC 20010
Published online May 4, 2017. (pmudd@cnmc.org).

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 Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage
T
onsillectomy is one of the most commonly performed
surgical procedures in children, with more than 500 000
procedures performed each year in the United States.1
Clinical practice guidelines have been established to provide evi-
dence for high-quality perioperative care among patients un-
dergoing tonsillectomy.2 Recommendations for corticosteroid
use, antibiotic use, and pain management are included. The
guidelines also recommend monitoring one of the common yet
serious outcomes of tonsillectomy, posttonsillectomy hemor-
rhage (PTH). Although many studies have evaluated the risk as-
sociations of postoperative pain management and PTH, few
studies have qualified the severity of PTH, with the exception
of specifying the need for surgical control of PTH (sPTH).3,4
Ibuprofen is a nonsteroidal anti-inflammatory drug that acts
by inhibiting cyclooxygenase and thereby inhibiting prosta-
glandin synthesis. Prostaglandins are local mediators of fever,
inflammation, and pain. As a nonselective cyclooxygenase in-
hibitor, ibuprofen additionally inhibits platelet aggregation and
increases bleeding time through inhibition of thromboxane A2.5
Therefore, ibuprofen has the potential to increase postopera-
tive hemorrhage. Recent evidence, however, suggests that
ibuprofen is not associated with an increased risk for PTH.6,7 The
most recent guidelines, published in 2011, support the use of
ibuprofen in postoperative pain management.2 Based on the lit-
erature and these guidelines, postoperative pain management
protocols were modified for children undergoing tonsillec-
tomy or adenotonsillectomy at Childrens Hospital of Philadel-
phia (CHOP) by routinely prescribing ibuprofen beginning Janu-
ary 1, 2013. The standard prescribed dose of ibuprofen was
7 mg/kg administered every 6 hours in addition to a combina-
tion of acetaminophen (10 mg/kg) and oxycodone hydrochlo-
ride (0.075 mg/kg). In May 2014, the use of ibuprofen was
stopped because of clinical observations suggesting that the
severity of PTH had increased, which may have had links to ibu-
profen use. Therefore, a retrospective review of all patients
undergoing tonsillectomy before and after ibuprofen imple-
mentation was performed to determine whether the clinical
observation could be validated statistically. Emergency trans-
fusion, defined as a transfusion in the emergency department
or during sPTH, was used as a surrogate of severity of PTH.
Methods
The population of interest included patients undergoing ton-
sillectomy or adenotonsillectomy since implementation of the
inpatient electronic health record (EHR) at CHOP in 2011, al-
lowing inclusion of approximately 2 years of patient data be-
fore and 2 years after ibuprofen was included as part of stan-
dard postoperative pain control protocols. This retrospective
cohort study included patients from January 1, 2011, through
June 30, 2014. The patients were identified in the EHR (Epic
Systems Corporation). Inclusion criteria consisted of all
patients undergoing tonsillectomy (Current Procedural
Terminology [CPT] code 42825/42826) or tonsillectomy and ad-
enoidectomy (CPT code 42820/42821) at all surgical facilities
(1 main operating room and 3 ambulatory surgical centers). Pa-
tients who underwent sPTH after the primary procedure was
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Original Investigation Research
Key Points
Question Is the severity of posttonsillectomy hemorrhage
requiring surgical control correlated with ibuprofen use?
Findings In this retrospective cohort study of 8868 pediatric
patients undergoing tonsillectomy, 222 (3.3%) required surgical
intervention for posttonsillectomy hemorrhage, with no
correlation between hemorrhage requiring surgical control and
ibuprofen exposure. Fifteen children (0.2%) required transfusion;
children using ibuprofen had an increased risk for transfusion
when hemorrhage occurred.
Meaning Ibuprofen used in postoperative management of pain
after tonsillectomy has not been shown to increase the overall risk
for posttonsillectomy hemorrhage; the severity of bleeding is
difficult to quantify but may be a more important outcome to
measure.
performed at an outside hospital and patients for whom the
EHR data were not accessible for validation were excluded. All
electronically derived data were deidentified. This study was
approved by the internal review board of CHOP, which quali-
fied the study as exempt from informed consent.
CHOP is a tertiary teaching childrens hospital with 13
pediatric otolaryngologyspecialized attending staff. Resi-
dent- and fellow-level trainees are involved in surgical cases.
The standard surgical method at CHOP is complete tonsillec-
tomy using monopolar cautery. A single surgeon routinely used
coblation for tonsillectomy in 2012 and then began to use mo-
nopolar cautery for tonsillectomy and coblation for adenoid-
ectomy and tonsillar fossae hemostasis. Suture is not rou-
tinely used for tonsillectomy or for treatment of PTH. Cases
could not be specifically examined for technique with our data
set, however; previous studies have not shown a significant dif-
ference in PTH rates.8-10 Standard anesthetic regimen at CHOP
includes sevoflurane induction with intermittent propofol and
opioid (fentanyl citrate or morphine sulfate), or nondepolariz-
ing muscle relaxants may be used as indicated throughout the
procedure. Dexamethasone sodium phosphate is routinely ad-
ministered. Dexmedetomidine hydrochloride was introduced
in 2012 but was not used routinely during the study period. Most
readmissions for PTH are managed surgically at CHOP.
The initial cohort was identified from hospital billing
records through querying for patient encounters with the afore-
mentioned CPT codes. The sPTH group was identified by que-
rying control of oropharyngeal hemorrhage requiring second-
ary surgical intervention (CPT code 42962). Each case was
specifically queried for age, preoperative diagnosis, and use
of ibuprofen in postoperative pain management. Patients were
assigned to the ibuprofen exposure group if they received ibu-
profen before discharge from the hospital or if they were given
an ibuprofen prescription for use after discharge. Patients who
required secondary sPTH underwent screening for blood trans-
fusions occurring in the 30-day period after tonsillectomy using
an internal review boardapproved study on evaluation of cur-
rent surgical blood order practice at CHOP. The postoperative
day of return for operative intervention indicated for PTH was
also recorded.
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 Research Original Investigation
Table 1. Demographic Characteristics of Multivariate Analysisa
Patients
Total Without sPTH,
Clinical Characteristic No. No. (%)
Full cohort 6710 6488 (96.7)
Ibuprofen exposure 2122 2060 (97.1)
No ibuprofen exposure 4588 4428 (96.5)
Age, y
<12 6012 5841 (97.2)
12 698 647 (92.7)
Preoperative diagnosis
OSA/SDB 5520 5361 (97.1)
Tonsillitis 1190 1127 (94.7)
Abbreviations: OSA/SDB, obstructive sleep apnea/sleep-disordered breathing;
sPTH, surgically managed posttonsillectomy hemorrhage.
Multivariate analysis was completed for patients who had
complete information available in the clinical data ware-
house, including age (younger than 12 years vs 12 years or older
based on surgical CPT code that recognizes a difference be-
tween these age groups), preoperative diagnosis (sleep-
disordered breathing and/or obstructive sleep apnea [SDB/
OSA] vs tonsillitis), and whether an ibuprofen prescription was
issued (yes or no). The preoperative diagnosis was retrieved
from the surgical procedure notes via text mining. The surgi-
cal procedure notes used standard text descriptions that were
mapped to SDB/OSA or tonsillitis. The EHR problem list was
queried with International Classification of Diseases, Ninth
Revision (ICD-9) codes 474.0 to 474.9 for tonsillar disease.
Manual review of the preoperative assessment at the ear, nose,
and throat clinic was performed for patients with PTH who did
not have a preoperative diagnosis available for database ex-
traction and for patients with other chronic diseases of the ton-
sils and adenoids (ICD-9 code 474.8) or unspecified chronic dis-
eases of tonsils and adenoids (ICD-9 code 474.9).
Multivariate logistic regression analysis was applied to the
dependent variables sPTH and sPTH with transfusion, with the
following independent variables: (1) age categorized as younger
than 12 years or 12 years or older, (2) preoperative diagnosis
categorized as OSA (inclusive of SDB and obstructive tonsillar
hypertrophy with or without adenoid hypertrophy) and re-
current tonsillitis (including a subgroup of patients with SDB/
OSA and recurrent tonsillitis [<2%]), and (3) ibuprofen expo-
sure categorized as yes or no. Additional variables described
included the timing of occurrence of sPTH as early (post-
operative day 0-1 [24 hours]) vs late (postoperative day 2 or
longer [>24 hours]), administration of blood transfusion within
30 days after adenotonsillectomy, and the number of pa-
tients requiring more than 1 sPTH. Statistical analysis was con-
ducted with STATA software (version 13; StataCorp) using mul-
tivariate logistic regression.
Databases queried included (1) the EHR (Epic Systems
Corporation) to identify all patients undergoing tonsillec-
tomy or adenotonsillectomy as well as sPTH and to extract
medications administered in the hospital and prescriptions at
discharge, (2) the anesthesia information management sys-
tem (CompuRecord; Philips) to identify intraoperative trans-
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Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage
Patients With sPTH, No. (%)
All Early (24 h) Late (>24 h) Transfusion
222 (3.3) 34 (0.5) 188 (2.8) 15 (0.2)
62 (2.9) 9 (0.4) 53 (2.5) 8 (0.4)
160 (3.5) 25 (0.5) 135 (2.9) 7 (0.2)
171 (2.8) 30 (0.5) 141 (2.3) 14 (0.2)
51 (7.3) 4 (0.6) 47 (6.7) 1 (0.1)
159 (2.9) 30 (0.5) 129 (2.3) 12 (0.2)
63 (5.3) 4 (0.3) 59 (5.0) 3 (0.3)
a
In multivariate analysis, a second sPTH in the same patient was not recounted.
Percentages have been rounded and may not sum to totals.
fusions, and (3) the blood bank database (Meditech) to iden-
tify all patients receiving blood products within 30 days after
tonsillectomy or adenotonsillectomy. Data were validated using
randomly selected medical records for manual review from an
existing quality improvement database. The primary focus of
the data review was to identify the frequency of patients re-
quiring sPTH. A surrogate for severity was explored through
capturing transfusion requirements in volume per body mass
(milliliters per kilogram). A manual review of all patients who
received transfusion in the postoperative period was com-
pleted for further validation.
The data query was unable to identify patients who
presented with PTH and did not require sPTH. The primary out-
come of this study was to determine the correlation of
severity of sPTH with ibuprofen exposure.
Results
We identified 8868 patients as having undergone tonsillectomy
(or adenotonsillectomy) from January 20, 2011, through June
30, 2014. A total of 6710 patients (3454 male [51.5%] and 3256
female [48.5%]; median age, 5.4 years [interquartile range, 3.7-
8.2 years]) met inclusion criteria for analysis. Two hundred
thirty-five medical records (3.5%) required manual validation.
All 6710 patients, including all 222 patients presenting with sPTH
(3.3%), were included in the multivariate analysis (Table 1). None
of the 2158 patients excluded from the study experienced the
sPTH outcome. The mean and mode for age were 6.5 and 3.4
years. Most of the patients were younger than 12 years.
Twenty patients (0.3%) during the 4-year study period pre-
sented with subsequent recurrence of sPTH after initial sPTH.
This group consisted of 7 patients exposed to ibuprofen and 13
not exposed to ibuprofen. Two patients in this group received
transfusions, both of whom were younger than 12 years and were
in the ibuprofen exposure group. For both patients, the trans-
fusion was received during the second sPTH procedure.
The cumulative 4-year rate of sPTH in our multivariate co-
hort was 3.3%, with 20 patients (0.3%) requiring more than 1
surgical exploration for hemorrhage control. Fifteen patients
(0.2%) required transfusion. A total of 2122 patients (31.6%)
jamaotolaryngology.com
 Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage
were exposed to ibuprofen, which was primarily confined to
the years 2013 and 2014 after implementation of new postop-
erative tonsillectomy pain management protocols. Among the
2122 patients with ibuprofen exposure, 62 (2.9%) had sPTH
compared with 160 of 4588 (3.5%) not exposed to ibuprofen.
Ibuprofen exposure was not associated with sPTH (adjusted
odds ratio [OR], 0.90; 95% CI, 0.68-1.19). Both age 12 years or
older (adjusted OR, 2.74; 95% CI, 1.99-3.76) and preoperative
diagnosis of recurrent tonsillitis (adjusted OR, 1.52; 95% CI, 1.12-
2.06) were independently associated with sPTH (Table 2).
Transfusion associated with secondary surgical interven-
tion was used as a marker for increased severity of hemor-
rhage. All patients requiring transfusion after tonsillectomy or
adenotonsillectomy required sPTH. Of all patients undergoing
tonsillectomy (or adenotonsillectomy), 15 (0.2%) received a
transfusion, including 8 patients in the ibuprofen exposure
group. Of the 222 patients undergoing sPTH, 15 underwent trans-
fusion for a cumulative 4-year transfusion rate of 6.8%. The sPTH
group consisted of 62 patients exposed to ibuprofen with 8 trans-
fusions (12.9%) and 160 patients not exposed to ibuprofen with
7 transfusions (4.4%) for an absolute difference of 8.5% (95%
CI, 0.1%-19.3%). Logistic regression analysis of sPTH with trans-
fusion did not find association with age (adjusted OR, 0.28; 95%
CI, 0.04-2.28) or preprocedure diagnosis (adjusted OR, 1.02;
95% CI, 0.26-3.99). Ibuprofen exposure was associated with a
3-fold higher risk for transfusion during sPTH (adjusted OR, 3.16;
95% CI, 1.01-9.91), suggesting a significant association of ibu-
profen with more severe bleeding, with the upper limit of the
95% CI suggesting that the increased severity risk could be nearly
10 times greater (Table 3).
Discussion
Ibuprofen use has become more acceptable and widespread
in controlling postoperative pain in patients who have had ton-
sillectomy, likely relating to the recently published American
Academy of OtolaryngologyHead and Neck Surgery Founda-
tion clinical practice guidelines, which include reviews of criti-
cal papers suggesting that the hemorrhage rate is not elevated.2
The most recent prospective randomized trial comparing the
use of ibuprofen with narcotic-based postoperative pain man-
agement in patients after tonsillectomy found no increased risk
for hemorrhage with ibuprofen. However, a significant in-
crease in postoperative hypoxemia was seen in patients re-
ceiving opioids.11 Conclusions from the study question the im-
plication of using opioids at all in children aged 1 to 10 years
because the risk outweighs the benefit of ibuprofen and acet-
aminophen, which have consistently been shown to have
equivalent analgesia rates. Although analgesia was not exam-
ined in this study, we have shown that rate of sPTH is not sig-
nificantly increased with use of ibuprofen.
Few studies have evaluated the severity of sPTH as a di-
rect function of ibuprofen use likely in part because determin-
ing whether the quantity of blood loss relates to the hemor-
rhage severity or the timing of presentation to the emergency
department is difficult. Attempts to examine trends in hemo-
globin level nadir or cumulative change in hematocrit level
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Original Investigation Research
Table 2. Multivariate Analysis for sPTHa
sPTH Variable Adjusted OR (95% CI)
Age 12 y 2.74 (1.99-3.76)
Preoperative diagnosis of tonsillitis 1.52 (1.12-2.06)
Ibuprofen exposure 0.90 (0.68-1.19)
Abbreviations: OR, odds ratio; sPTH, surgically managed posttonsillectomy
hemorrhage.
a
Includes 6710 patients.
Table 3. Allogeneic Blood Product Transfusion
Within 30 Days of Tonsillectomya
Transfusion Variable Adjusted OR (95% CI)
Age 12 y 0.28 (0.035-2.28)
Preoperative diagnosis of tonsillitis 1.02 (0.26-3.99)
Ibuprofen exposure 3.16 (1.01-9.91)
Abbreviation: OR, odds ratio.
a
Includes 222 patients. One patient received a transfusion for preoperative
anemia related to sickle cell disease and did not require intervention for
posttonsillectomy hemorrhage.
were unsuccessful owing to the lack of standardization of when
the hemoglobin and hematocrit results were obtained in as-
sociation with timing of hemorrhage and because this infor-
mation was recorded in multiple portions of the EHR at dif-
ferent times. In most cases, the hemorrhage starts when
patients are outside the hospital and swallow blood, making
it difficult to quantify the blood volume lost during this pe-
riod. Therefore, in our study, transfusion rate was used as a
marker of severity in sPTH. We found a statistically signifi-
cant and clinically meaningful increased rate of transfusion
with sPTH among patients with ibuprofen exposure. The 95%
CI is very wide owing to the small number of outcome events
(only 15 patients required transfusion). This 95% CI suggests
that the association of ibuprofen with more severe bleeding
that requires transfusion could be anywhere from a 1-fold to a
nearly 10-fold increase (the upper limit of the 95% CI is 9.91).
A larger study is needed to generate a more precise estimate
of effect. We found no association between patient age and pre-
operative diagnosis of tonsillitis and ibuprofen use.
Few previous studies have evaluated transfusion risk in
PTH. In a small study examining the risk for transfusion in 100
patients undergoing tonsillectomy during a 9-year period,12 the
rate of hemorrhage was 6% and the rate of transfusion was 3%.
Two of the 3 patients receiving a transfusion in that cohort had
abnormal coagulation profiles. A postoperative pain manage-
ment protocol was not mentioned in that study. Children with
von Willebrand disease or hemophilia face an increased risk
for PTH, with a rate of 15% reported in a UK study13 that in-
cluded 500 high-risk patients. The rate of transfusion in that
group was 2.4%, but the effect of postoperative pain manage-
ment protocols was not mentioned.
In the literature, the reported rate of transfusion after PTH
is low and is consistent with the findings in our large cohort. This
study is the first, to our knowledge, to examine transfusion risk
as a surrogate for severity of sPTH in a large cohort. The asso-
ciation of ibuprofen implementation and rate of transfusion is
715
 Research Original Investigation Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage

important to consider in counseling patients and may have spe-
cific implications in resuscitation management protocols for pa-
tients with severe PTH. Furthermore, transfusion rates in PTH
require monitoring and reporting to determine whether the
widespread increase in the severity of PTH is in fact associated
with ibuprofen use. Last, ibuprofen dose standardization has
not been examined to determine the minimal threshold for
optimal analgesia or the dose-dependent risk of PTH.
Limitations
The nature of the study using database acquisition relies on cor-
rect data entry. Furthermore, changes in postoperative pain
management by a parent or outside clinician may have added
ibuprofen, which cannot be captured and would lead to some
patients in the nonexposure group having had exposure to ibu-
profen and therefore a possible crossover effect that cannot be
captured with our data set. Platelet function usually returns to
normal within 12 hours after administration of ibuprofen,5 and
the relative timing of the last dose of ibuprofen in association
with the timing of hemorrhage cannot be captured and may be
relevant. In addition, standardization in dosing regimen can-
not be clarified and thus may also weaken the conclusion of this
study. Based on these limitations, we believe it is prudent to con-
sider standardized dosing and administration of ibuprofen with
prospective follow-up of outcomes that include rates of trans-
fusion. Finally, standardized documentation of readmission
characteristics of patients with PTH can aid in understanding
of the true effect of ibuprofen on sPTH and clinical course, spe-
cifically 24-hour medication reconciliation at the time of read-
mission and clear documentation regarding bleeding history, in
addition to routine preresuscitation and postresuscitation
hematocrit and hemoglobin levels.
Given that the severity of PTH is difficult to quantify and
the incidence of the most severe complications is very small,
our field must continue to evaluate these complications in
multi-institutional outcome registries at regional or national
levels. The PTH rate is low, and the rate of transfusion even
lower; thus, to demonstrate definitely whether an associa-
tion exists between ibuprofen and severe sPTH, a much larger
patient sample would be required.
Multiple assumptions are made in this study. Patients who
received a prescription for ibuprofen were considered as ex-
posed to the medication. We cannot determine how many
times the medication was administered from the existing da-
tabases nor the temporal association with ibuprofen use and
the time of hemorrhage. Including only those patients who re-
quire sPTH limits the ability to make conclusions regarding all
readmissions for PTH. The data retrieval techniques used limit
our ability to examine patients individually to understand in-
dications and variation in techniques. Posttonsillectomy hem-
orrhage is likely to be a multifactorial problem, and account-
ing for all variables that contribute to it may be difficult.
Querying clinical data sets such as this one may pose addi-
tional challenges because often data are not recorded consis-
tently in the same way over time.14 Future efforts to study pa-
tient outcomes will benefit from ongoing standardization of
EHR at a national level and can build on frameworks, such as
the one described in this study, when evaluating large patient
populations.
Conclusions
Tonsillectomy is one of the most common surgical proce-
dures performed in children. Monitoring critical outcomes of
tonsillectomy aims to improve the quality of surgical care. Ad-
ditional investigations of postoperative pain management pro-
tocols that optimize analgesia while achieving the maximal
safety profile are ongoing. Ibuprofen is now widely used in
postoperative management of patients undergoing tonsillec-
tomy. The risk for PTH was not increased overall with the post-
operative use of ibuprofen; however, a statistically signifi-
cant and clinically meaningful independent increased risk was
found among ibuprofen users 12 years or older who had pre-
operative diagnosis of recurrent tonsillitis. In addition, this co-
hort is, to our knowledge, the first and largest to specifically
examine transfusion rates in sPTH as a surrogate marker for
severity. The data suggest a statistically significant and clini-
cally meaningful increase in the use of transfusion products
among ibuprofen users. Additional studies are warranted to
investigate this association before any definitive conclusions
can be made regarding the potential risk for severe hemor-
rhage with routine prescription of nonsteroidal anti-
inflammatory medications for posttonsillectomy analgesia.
Prospective monitoring of hemorrhage inclusive of the sever-
ity of hemorrhage and the rates of transfusion should be con-
sidered for ongoing and future outcomes-based projects for
adenotonsillectomy.

ARTICLE INFORMATION
Accepted for Publication: January 28, 2017.
Published Online: May 4, 2017.
doi:10.1001/jamaoto.2016.3839
Author Affiliations: School of Medicine and Health
Sciences, George Washington University,
Washington, DC (Mudd); Division of Pediatric
Otolaryngology, Childrens National Medical Center,
Washington, DC (Mudd); Department of
Anesthesiology and Critical Care Medicine,
Childrens Hospital of Philadelphia, Philadelphia,
Pennsylvania (Thottathil, Glvez); Department of
Anesthesiology and Critical Care Medicine,
Perelman School of Medicine, University of
Pennsylvania, Philadelphia (Thottathil, Glvez);
Division of Otolaryngology (Ear, Nose, and Throat),
Childrens Hospital of Philadelphia, Philadelphia,
Pennsylvania (Giordano, Wetmore, Elden);
Department of OtorhinolaryngologyHead and
Neck Surgery, Childrens Hospital of Philadelphia,
Philadelphia, Pennsylvania (Wetmore, Elden);
Department of Biostatistics in Pediatrics, Perelman
School of Medicine, University of Pennsylvania,
Philadelphia (Jawad); Enterprise Reporting and
Analytics, Childrens Hospital of Philadelphia,
Philadelphia, Pennsylvania (Ahumada); Section of
Biomedical Informatics, Department of
Anesthesiology and Critical Care Medicine,
Childrens Hospital of Philadelphia, Philadelphia,
Pennsylvania (Ahumada, Glvez); Department of
Biomedical and Health Informatics, Childrens
Hospital of Philadelphia, Philadelphia, Pennsylvania
(Glvez).
Author Contributions: Drs Jawad and Ahumada
had access to data for purposes of database and
statistical analysis, respectively. Drs Mudd and
Glvez had full access to all the data in the study
and take responsibility for the integrity of the data
and the accuracy of the data analysis.
Study concept and design: Mudd, Wetmore, Jawad,
Glvez.
Acquisition, analysis, or interpretation of data: All
authors.

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 Association Between Ibuprofen Use and Surgically Managed Posttonsillectomy Hemorrhage
Drafting of the manuscript: Mudd, Wetmore,
Glvez.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Thottathil, Jawad, Ahumada,
Glvez.
Administrative, technical, or material support:
Glvez.
Study supervision: Wetmore, Elden, Glvez.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Meeting Presentation: This paper was presented
at the Annual Meeting of the American Society of
Pediatric Otolaryngology; April 25, 2015; Boston,
Massachusetts.
Additional Contributions: David Friedman, MD,
transfusion service at Childrens Hospital of
Philadelphia (CHOP), contributed to the transfusion
data, and Mohamed Rehman, MD, Department of
Anesthesiology, CHOP, offered guidance and critical
contributions to the study concept. Neither
contributor was compensated for this work.
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