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Tonsillectomy bleed (hemorrhage) management (post-tonsillectomy hemorrhage)

return toTonsillectomy and Adenoidectomy

see also: Common Call Problems;  Medical Student Resident Page for Otolaryngology

1. GENERAL CONSIDERATIONS

A. 

   I. Tonsillectomy is one of the most commonly performed procedures by Otolaryngologists, with over 500,000 performed annually in the United States.   

   II. Tonsillectomy in children is most commonly performed for obstructive sleep apnea and recurrent episodes of tonsillitis. In adults (aged 18 years and older), indications for tonsillectomy can be for a variety of reasons, including the increasing incidence of tonsillar squamous cell carcinoma. 

   III. Multiple techniques are used to perform a tonsillectomy, and there is no clear consensus on which technique has the lowest rates of post-tonsillectomy hemorrhage. 

   IV. Post-tonsillectomy hemorrhage is considered a surgical emergency. Hemorrhage after tonsillectomy can be classified as primary or secondary. If bleeding occurs within the first 24 hours after surgery, it is referred to as a primary hemorrhage. Secondary hemorrhage risk occurs after 24 hours. 

   V. All patients and parents of minors should be appropriately counseled pre-operatively about the risk of hemorrhage post-operatively. The risk of primary hemorrhage is 0.2-2.2%, and secondary hemorrhage is 0.1-4.8%. 

   VI. Many factors have been associated with an increase in the risk of post-tonsillectomy hemorrhage, including age >5, chronic tonsillitis, and aspirin usage pre-operatively. 

   VII. In children with hemophilia or Von Willibrand Disease, rates of hemorrhage immediately after tonsillectomy are similar but are substantially higher with delayed hemorrhage. 

   VIII. For patients with an increased risk of post-operative hemorrhage, evaluation of basic pre-operative laboratory values should be completed. Platelet count, hemoglobin level, and plasma clotting variables should be assessed. 

2. PREOPERATIVE PREPARATION 

A. DIAGNOSIS AND MANAGEMENT

Patients are often initially encountered in an emergency department setting. The patient should be sitting upright, with suction available for active bleeding.  Inspection of the oral cavity and oropharynx must be performed, including a thorough inspection of the tonsillar fossa. Physical exam will either reveal no active bleeding, active bleeding, or presence of a clot in the tonsillar fossa. Intravenous access should be obtained early and not delayed until the operating room theater. Patients will often need volume resuscitation. This allows for quick access should the patient's respiratory status acutely decline. Basic labs, including a hemoglobin and hematocrit, should be drawn. If there has been a significant decrease in red blood cell volume, consideration should be given regarding a transfusion. 

The degree of bleeding and age will often help dictate whether a patient will need to return to the operating room for cauterization. If a patient is not actively bleeding, or there is less than 1 tablespoon, some providers choose close observation. If a patient is actively bleeding, the patient should be taken urgently for control of the hemorrhage. Until the patient is transferred to the operating room, if hemorrhaging is significant, direct pressure, either with a throat pack or gauze, should be applied to the tonsillar fossa if the patient is cooperative. 

Control of hemorrhage was historically managed with suture ligation, but suction cautery is more routinely performed today. Suction cautery results in less operating time and a decreased amount of intraoperative blood loss. If bleeding is controlled under local anesthesia, hurricaine spray (benzocaine) may be used for initial anesthetization, followed by viscous lidocaine or a local injection of lidocaine. Local cauterization may be attempted with bipolar cautery or silver nitrate. 

POST-TONSILLECTOMY BLEED MANAGEMENT ALGORITHM:

B. CONSENT (Describe potential complications) 

   I. Damage to lips, teeth, tongue

   II. Further bleeding 

   III. Dysphagia 

   IV. Aspiration 

   V. Death

3. NURSING CONSIDERATIONS

Tube Placement: The ET (we prefer oral rae) tube should be placed at exactly midline and brought inferiorly. 

A shoulder roll may be used to improve neck extension and optimize the view of operative field.

Special consideration for Down Syndrome (Trisomy 21):

Due to risk of atlanto-axial instability (AAI) in these patients, caution should be used in head positioning, including no shoulder roll and minimal head tilting.

Preoperative x-rays or recent scans should be reviewed prior to the operation date.

Laxity of over 4 mm suggests axial-atlanto instability; due to a low level sensitivity in flexion/extension films in detecting AAI, it is suggested to take neck precautions in all patients with Down Syndrome.

Carefully place the Crowe-Davis retractor. 

Ensure that the tongue blade is the appropriate size.

This should extend far enough to allow for retraction of the base of tongue but not be too long as to damage the posterior pharyngeal wall. 


The tongue may be manipulated into the correct position with the Hurd retractor or blunt Yankauer suction tip

4. ANESTHESIA CONSIDERATIONS

Patients with a post-tonsillectomy hemorrhage, especially children, can have significant associated hazards. Patients with a post-tonsillectomy hemorrhage may have associated anemia, hypovolemia, and sequestered blood in the stomach, which leads to a theoretical increase risk in aspiration. In the emergent setting, rapid sequence intubation (RSI) is often performed. RSI includes cricoid pressure, an induction agent, neuromuscular blocking agent, but no mask ventilation, followed by a quick intubation by anesthesia. 

5. OPERATIVE PROCEDURE (example) 

After written informed consent was obtained, the patient was brought back to the operating room by Anesthesia and placed supine on the operating room table. A pre-induction checklist was performed. An IV was placed, and the patient was mask ventilated.  Rapid sequence intubation was performed, and the patient was orotracheally intubated without difficulty.  The bed was turned 90 degrees from Anesthesia.  A Crowe-Davis retractor was placed with good visualization of the oropharynx.  Eschar was noted in the left inferior tonsil bed, partially dislodged, but with no bleeding.  After a small amount of clot was removed, left inferior pole slow oozing began and was controlled with bipolar cautery set at 20. The right tonsil fossa was examined with no evidence of blood or clot.  Valsalva to 30 was performed with no bleeding. The stomach was suctioned multiple times.  The patient was then taken out of suspension and the Crowe-Davis was removed. The patient's mouth was wiped clean and then turned back to Anesthesia in stable condition.  The patient was then extubated uneventfully.

References: 

1. Wall JJ, Tay K-Y. Postoperative Tonsillectomy Hemorrhage. Emerg Med Clin North Am. 2018;36(2):415-426. doi:10.1016/j.emc.2017.12.009

2. Breinholt CC, Obr CJ. General Anesthesia for a Posttonsillectomy and Adenoidectomy Bleed. MedEdPORTAL  J Teach Learn Resour. 2016;12:10476. doi:10.15766/mep_2374-8265.10476

3. Fields RG, Gencorelli FJ, Litman RS. Anesthetic management of the pediatric bleeding tonsil. Paediatr Anaesth. 2010;20(11):982-986. doi:10.1111/j.1460-9592.2010.03426.x

4. Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014;48(1):62-76. doi:10.1177/1060028013510488

5. Handler SD, Miller L, Richmond KH, Baranak CC. Post-tonsillectomy hemorrhage: incidence, prevention and management. Laryngoscope. 1986;96(11):1243-1247. http://www.ncbi.nlm.nih.gov/pubmed/3773625.

6. Escobar M, Maahs J, Hellman E,  et al.  Multidisciplinary management of patients with haemophilia with inhibitors undergoing surgery in the United States: perspectives and best practices derived from experienced treatment centres.  Haemophilia. 2012;18(6):971-98122776076

7. Sun et al. Posttonsillectomy Hemorrhage in Children With von Willebrand Disease or Hemophilia. JAMA Otolaryngology - Head and Neck Surgery. 2013;139(3):245-249. doi:10.1001/jamaoto.2013.1821