Post-tonsillectomy hemorrhage following ketorolac in children: A 2010-2024 national database analysis

To determine whether ketorolac improves clinical outcomes without increasing the risk of a primary post-tonsillectomy hemorrhage. We hypothesized that early administration of ketorolac following a tonsillectomy would be associated with decreased health care utilization without increasing the risk of a primary post-tonsillectomy hemorrhage.

We performed a retrospective cohort study using a national administrative claims dataset of pediatric tonsillectomies performed between 2010 and 2024. Children younger than 19 years undergoing tonsillectomy with or without adenoidectomy were included; those with bleeding disorders were excluded. Exposure was defined as ketorolac administration within 24 h postoperatively. Primary outcomes were PTH within 14 days and return to the operating room within 48 h. Secondary outcomes included time-to-hemorrhage using Kaplan-Meier analysis, hemorrhage hazard via Cox proportional hazards modeling, ED utilization, and total 14-day episode-of-care cost.

Among 1,958,742 pediatric tonsillectomies, 2208 (0.11%) patients received ketorolac. PTH occurred in 1.90% of ketorolac recipients compared to 1.02% without ketorolac (P < .0001). Return to the operating room within 48 h occurred in 0.72% vs. 0.12% (P < .0001). Kaplan-Meier analysis demonstrated significantly earlier bleeding among ketorolac recipients (log-rank P = .00003). Cox modeling demonstrated increased hazard of hemorrhage among ketorolac recipients (HR 1.88; 95% CI, 1.39-2.55; P < .005). ED utilization within 14 days was significantly higher among ketorolac recipients. Mean 14-day cost was $1743 among ketorolac recipients and $1350 among non-recipients (+29%).

Immediate postoperative ketorolac use was associated with increased and earlier PTH, greater early ED utilization, and higher short-term healthcare cost. These findingscontribute important contemporary evidence regarding the association between ketorolac use and hemorrhage-related outcomes following pediatric tonsillectomy.