Episode Transcript
Hello, welcome to the Anesthesia Toolbox Podcast on post-tonsillectomy hemorrhage. My name is Debnath Chatterjee, and I’m a pediatric anesthesiologist at the Children’s Hospital Colorado and the University of Colorado. I do not have any financial disclosures.
The learning objectives of this podcast are as follows. Upon completion of this podcast, listeners will be able to:
1. Describe the most common clinical presentation of post-tonsillectomy hemorrhage.
2. Recognize the signs and symptoms of hypovolemia in children.
3. Formulate an anesthetic plan for a child presenting with post-tonsillectomy hemorrhage.
The clinical scenario is as follows. You are on call, and the ENT surgeon wants to take a 4-year-old boy to the OR for control of post-tonsillectomy hemorrhage. The boy presented to the ED after spitting out some blood. He had his tonsils and adenoids removed as an outpatient 5 days back. The child's mother reports poor PO intake over the last couple of days. The ED nurse also states that the patient nearly passed out going to the bathroom. How would you evaluate this child, and what is your anesthetic plan?
Tonsillectomy, with or without adenoidectomy, is one of the most common surgical procedures in children. Based on 2010 estimates, approximately 300,000 tonsillectomies are performed in the United States every year. Common indications include sleep-disordered breathing and recurrent tonsillitis. However, tonsillectomy can be associated with several complications, including post-operative pain, respiratory complications, bleeding, nausea/vomiting, and dehydration.
Post-tonsillectomy hemorrhage remains one of the most common complications and is seen in 2-5% of all patients. PTH can be categorized into primary bleeding, which occurs within the first 24 hours following surgery, and secondary bleeding, which typically occurs 5-12 days following surgery. Primary bleeding is generally attributed to surgical technique and the reopening of blood vessels and is seen in 0.2 to 2.2% of patients. Secondary bleeding is usually caused by sloughing of the primary eschar, and the rates range from 0.1 to 3%.
Risk factors for PTH include surgical technique, age > 5 years, recurrent tonsillitis, and preoperative use of aspirin and NSAIDs. A “hot” electrosurgical, cautery dissection technique is more likely to cause PTH than “cold” ligation of vessels and use of a knife, scissors, or snare technique. There is evidence that an “intracapsular” tonsillotomy may reduce the incidence of PTH. PTH can result in several complications, such as hematemesis, anemia, hypovolemia, and even death. These patients frequently return to the OR for cauterization of the bleeding tonsillar fossa.
Preoperative evaluation should include a detailed history and physical examination to assess the degree of hypovolemia. Clinicians must ask parents and caregivers about episodes of vomiting or hematemesis, amount and type of oral intake, urine output, and activity level. The overall appearance of the child, activity level, and response to stimulation must be observed. Evaluating the respiratory pattern is important, and hyperpnea (deep, rapid breathing without signs of respiratory distress) may suggest acidosis. The patient’s heart rate, blood pressure, skin turgor, and capillary refill time must also be evaluated. A history of dizziness and the presence of orthostatic hypotension suggests moderate hypovolemia.
Other signs of dehydration include sunken eyes, dry mucous membranes, cool extremities, weak pulses, absent tears, increased heart rate, sunken fontanelle, and poor overall appearance. The three best individual examination signs for assessing dehydration are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern.
Laboratory testing is less useful for assessing the degree of hypovolemia in children. In children with hemorrhagic shock, the initial hematocrit may be normal because equilibration with extracellular fluid has not yet occurred. However, the hematocrit will drop with repeated measurements over time.
Intravenous fluid therapy with isotonic crystalloids, such as normal saline or lactated Ringer’s solution, is recommended for the initial resuscitation of hypovolemic patients. Children with hypovolemic shock may receive 20 mL/kg per bolus of isotonic crystalloid over 5-20 minutes. Additional fluid boluses may be necessary depending on the patient’s clinical response. Patients with hemorrhagic shock should receive packed red blood cell transfusion in 10 mL/kg boluses. The use of tranexamic acid, either nebulized preoperatively or given IV in the OR, is being evaluated in ongoing studies.
The anesthetic management of a child with PTH poses several challenges. It involves dealing with anxious parents and a frightened child who may be anemic and hypovolemic, combined with a stomach full of blood. It is impossible to estimate the amount of blood loss as most of the blood from the oropharynx is swallowed, putting the child at risk for pulmonary aspiration. The child must be adequately volume resuscitated before proceeding to the operating room. In addition to standard ASA monitors, a styletted ETT, one or two well-functioning suctioning apparatuses, and additional airway equipment (extra laryngoscope handle/blade) must be readily available before induction.
Some authors recommend preoxygenating the child in the left lateral position with the head down to drain blood out of the mouth. After preoxygenation, a rapid sequence induction must be performed to facilitate endotracheal intubation. A reduced dose of an induction agent (propofol, etomidate, or ketamine) and a rapidly acting muscle relaxant (succinylcholine or rocuronium) may be used for rapid sequence induction. A cuffed endotracheal tube must be used to minimize the risk of aspiration. After intubation, the FiO2 should be reduced to decrease the risk of an airway fire during the use of electrocautery. Either a volatile agent or total intravenous anesthesia may be used for the maintenance of general anesthesia. These are usually short surgical cases, and short-acting medications should be used to facilitate early emergence. Upon completion of the procedure, a large bore orogastric tube must be used to decompress the stomach and evacuate the swallowed blood. Prophylactic administration of antiemetics is recommended. The patient may be extubated when fully awake and able to control their airway reflexes. In a retrospective review of post-tonsillectomy bleeds, Fields et al. reported that transient hypoxemia during emergence and extubation was the most common complication.
In summary, post-tonsillectomy hemorrhage remains one of the most common complications following tonsillectomy and adenoidectomy and is seen in 2-5% of all patients. PTH can be categorized into primary bleeding, which occurs within the first 24 hours following surgery and secondary bleeding, which typically occurs 5-12 days following surgery. Risk factors for PTH include surgical technique, age > 5 years, recurrent tonsillitis and preoperative use of aspirin and NSAID. Preoperative evaluation should include a detailed history and physical examination to assess the degree of hypovolemia. The child must be adequately volume resuscitated with isotonic crystalloids before proceeding to the operating room. After adequate preoxygenation, a rapid sequence induction must be performed to facilitate endotracheal intubation. The patient may be extubated when fully awake and able to control their airway reflexes.
