Post-Tonsillectomy Bleeding

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Tonsillectomy is a procedure performed in children and is referred to as surgical intervention with or without adenoidectomy¹. According to the research, tonsillectomy provided in children includes 90 percent of cases that were done as the infection aftermath^2.At that, airway obstruction is the main cause of the infection that is usually expressed in sleep apnea. The list of post tonsillectomy complications consists of pain, nausea, vomiting, dehydration, and several other factors. Pharyngeal tonsil is located in the nasopharynx. Therefore, after its removal, children become more prone to occurrence of colds as a natural protection against viruses and pathogenic bacteria in the nose and throat weakens. It should be noted that the pharyngeal tonsil influence the immune system, and, therefore, inflammation may occur against the backdrop of a weakened immune system. Undoubtedly, consequences of tonsillectomy are difficult to predict as they appear differently in each case³. The consequences of the removal of tonsils in children include following symptoms:

Temperature increase;
Nausea and vomiting after the procedure;
Voice change (only possible if the tonsils are too large);
Sore throat, jaw, and neck.

However, the most life-threatening symptoms might also occur. For example, bleeding is the most serious complication that needs to be reported to a doctor immediately^1(p144).One might categorize it as the primary and the secondary bleeding. In particular, the first one occurs within 24 hours after a surgery as a result of inadequate hemostasis while the latter appears after 24 hours due to premature sloughing of eschar or chronic tonsillitis⁴. According to practice, 67 percent of bleeding is originated in tonsillar fossa and 27 percent in the nasopharynx. In the case pharyngeal packs and cautery are ineffective, patients are treated using anesthesia. Also, the following procedures might be necessary to provide patients with appropriate treatment: arteriography, ligature of the external carotid artery, or selective embolization⁵.

It should be emphasized that the hemorrhage incidence of both primary and secondary bleeding accounts for approximately two and three percent, respectively^6,7,8. Namely, it depends on the research. Nevertheless, they occur most often in the first hours after the operation and less for 1.5-2 weeks after it⁹. At the same time, mortality evidence is rarely discussed in studies as its level is very low. Thus, in 2010, only 2 deaths occurred among 36, 211 tonsillectomy interventions¹⁰. Among the risk factors, there are gender, age, surgical equipment, and others. More to the point, the risk increases with age in males. Comparing “hot” and “cold” surgical techniques, it is possible to note that the risk of complications is higher in the first technique due to the use of bipolar diathermy¹¹. Both pertionsillar abscess and recurrent tonsillitis have greater risk of bleeding in comparison with obstructive syndrome¹².

Postsurgical bleeding is usually handled by operating surgeon while in the case of the secondary hemorrhage emergency care should be conducted. The package of intervention of anesthetic management includes the following points:

In three out of four cases hemorrhage occurs on day one after the surgery and two out of three of them appear in the first six hours after the surgery. Therefore, after the operation, the patient should be carefully observed. In some cases, blood loss is detected only during vomiting, when a large amount of blood is ejected at once. In this case the patient is usually pale and his pulse is frequent. Such a condition can quickly lead to shock and collapse, unless urgent actions are taken to stop further bleeding.
In patients with hypovolemia, it is essential to use rapid sequence induction and intubation (RSII) with low dose of induction agent and cricoid pressure.
Airway management should be prepared thoroughly and timely as well as the operating room¹³.
Laryngeal mask airway (LMA) is to be utilized in post tonsillectomy bleeding after originally attempted ETT was unsuccessful. The use of LMA-ProsealTM as a way to conduct flexible bronchoscope to the trachea and insertion of ETT over bronchoscope are also an alternative¹⁴. Complicated airway management might be challenging and cause anoxic brain injury¹⁵.
Intraoperative opioid use in the patient with OSA as a result of perioperative pulmonary complications is one of the most pressing problems in anesthesiology and intensive care due to their high frequency and required treatment¹⁶. Patients with OCA are more sensitive to opiod so anesthetic managers should be aware of that fact.
According to American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-NSF), intraoperative administration should be conducted in postoperative nausea and vomiting prophylaxis with a single dose of dexamethasone¹⁷. However, the influence of dexamethasone use in children with or without NSAID is not reported sufficiently and remains controversial¹⁸. However, a recent randomized trial study concluded increase of the risk of post tonsillectomy bleeding at 0.5 mg/kg dosage of dexamethasone. Due to the safety reasons the study was fully terminated¹⁹.
It is quite beneficial to keep the patients in Trendelenburg position to treat shock and facilitate pooling of blood.

References

Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011; 144:S1.
De Luca Canto G, Pachêco-Pereira C, Aydinoz S, et al. Adenotonsillectomy Complications: A Meta-analysis. Pediatrics. 2015; 136:702.
Peterson J, Losek JD. Post-tonsillectomy hemorrhage and pediatric emergency care. Clin Pediatr. 2004 ;43:445-448.
Johnson LB, Elluru RG, Myer CM 3rd. Complications of adenotonsillectomy. Laryngoscope. 2002; 112:35.
Windfuhr JP: Indications for interventional arteriography in posttonsillectomy hemorrhage. J Otolaryngol. 2002; 31:18–22.
De Luca Canto G, Pachêco-Pereira C, Aydinoz S, et al. Adenotonsillectomy Complications: A Meta-analysis. Pediatrics. 2015; 136:702.
Subramanyam R, Varughese A, Willging JP, Sadhasivam S. Future of pediatric tonsillectomy and perioperative outcomes. Int J PediatrOtorhinolaryngol. 2013; 77:194.
Lowe D, van der Meulen J, Cromwell D, et al. Key messages from the National Prospective Tonsillectomy Audit. Laryngoscope. 2007; 117:717.
Liu JH, Anderson KE, Willging JP, et al. Posttonsillectomy hemorrhage: what is it and what should be recorded? Arch Otolaryngol Head Neck Surg. 2001; 127:1271.
Shay S, Shapiro NL, Bhattacharyya N. Revisit rates and diagnoses following pediatric tonsillectomy in a large multistate population. Laryngoscope. 2015; 125:457.
Lowe D, Cromwell DA, Lewsey JD, et al. Diathermy power settings as a risk factor for hemorrhage after tonsillectomy. Otolaryngol Head Neck Surg. 2009; 140:23-28.
Ravi R, Howell T. Anaesthesia for paediatric ear, nose and throat surgery. Contin Educ Anaesth Crit Care Pain. 2007; 7: 33 –37.
Bissonnette B, Dalens BJ. Pediatric Anesthesia: Principles and Practice. New York, NY: McGraw-Hill; 2002.
Orlando Hung, Michael F. Murphy. Management of the Difficult and Failed Airway. New York, NY: McGraw-Hill; 2011.
Subramanyam R, Varughese A, Willging JP, Sadhasivam S. Future of pediatric tonsillectomy and perioperative outcomes. Int J PediatrOtorhinolaryngol. 2013; 77:194.
Karen A Brown, André Laferrière, IndraniLakheeram, ImmanuelaRavé Moss. Recurrent hypoxemia in children is associated with increased analgesic sensitivity to opiates. Anesthesiology. 2006; 105:665-669.
Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011; 144:S1.
Bellis JR, Pirmohamed M, Nunn AJ, et al. Dexamethasone and haemorrhage risk in paediatric tonsillectomy: a systematic review and meta-analysis. Br J Anaest. 2014; 113:23.
Czarnetzki C, Elia N, Lysakowski C, et al. Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a randomized trial. JAMA. 2008; 300:2621.

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Post-Tonsillectomy Bleeding

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