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Patient Characteristics and Postoperative Mortality in Children Undergoing Tonsillectomy—Reply
In Reply Our study of postoperative mortality associated with pediatric tonsillectomy was based entirely on a longitudinal analysis of inpatient and outpatient discharge data from 5 US states. These data provided no information about some of the factors (surgical technique, type of tonsillectomy, postoperative narcotic use) suggested by Dr Huang and colleagues as having possible relationships with mortality. Our analysis did include a case-by-case evaluation of diagnosis and procedure codes associated with preoperative, surgical, and postoperative encounters in all fatal cases. As stated in our study, we found that 28 of 36 fatal cases (77.8%) were associated with discharge codes indicating a life-threatening respiratory problem (respiratory failure, pulmonary edema, pneumonia, aspiration) or otherwise unexplained cardiac arrest and that the number of fatal cases associated with code(s) indicating hemorrhage was very small (exact number suppressed according to data use agreement). We cannot speculate about whether some cases of ostensibly isolated respiratory failure were in fact precipitated by unrecognized or unrecorded bleeding. However, our findings about cause of death were consistent with published information from provider surveys and malpractice claims that collectively described a total of 191 tonsillectomy cases with severe adverse outcomes (including 144 deaths). A total of 48 of 191 cases (25.1%) were attributed to bleeding, and the majority, 115 of 191 (60.2%), were attributed to isolated apnea, respiratory failure, or unexplained causes. Serious comorbid conditions, particularly neuromuscular disorders, were considered important co-factors in a number of cases. Taken together, this evidence confirms that bleeding remains an important but less common cause of tonsillectomy-related deaths than isolated respiratory complications. Whether rates of bleeding-related mortality could be further reduced by certain surgical techniques or type of tonsillectomy (partial vs total) is, to our knowledge, unknown and would require very large studies to evaluate. Huang and colleagues also express interest in whether obesity was associated with postoperative death in our study, but we found very few deaths (exact number suppressed) coded for this comorbidity and, accordingly, decided not to pursue a quantitative analysis of this potential factor.
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