Post-Tonsillectomy Bleed

Question 1

You are asked to review a 4-year-old male patient on the paediatric ward, who had a tonsillectomy 11 hours previously. He is bleeding, and the sur- geons want to take him back to theatre urgently.

What are the indications for a tonsillectomy in paediatric patients?

Answer 1

• Recurrent/persistent tonsillitis.
• Obstructive sleep apnoea.
• Tonsillar abscess.
• Lymphoma biopsy, or suspicious lump biopsy if unilateral tonsillar
  hypertrophy (rare).

Question 2

Which patients are at higher risk for a post-tonsillectomy bleed?

Answer 2

A primary haemorrhage occurs within 24 hours of the procedure and is usually due to venous/capillary ooze from failed haemostasis. A secondary haemorrhage occurs more than 24hours from the procedure and is usually due to infection, most commonly 5–10 days postoperatively.

• Patient factors – male, adults (compared to children), indication for tonsillectomy (infectious > obstructive).
• Surgical factors – diathermy technique and coblation for secondary bleed.

Question 3

What are your main concerns with regards to this patient?

Answer 3

• This is a high-risk paediatric patient.
• Medical and surgery emergency with potential hypovolaemic shock
  and ongoing blood loss.
• Risk of aspiration from full stomach (swallowed blood and postoperative oral intake) especially during induction of anaesthesia
  and extubation.
• Potential difficult airway and intubation due to local oedema, swelling and haemorrhage.
• Effect of residual anaesthetic and analgesic drugs prior to a second
  emergency general anaesthetic.
• Human factors for child, parents and theatre staff: anxiety/stress.

Question 4

How would you assess this patient on the ward?

Answer 4

• Carry out a rapid ABCDE assessment to identify the risk of airway obstruction and the presence of hypovolaemic shock.
• The volume of blood loss can be difficult to quantify as the patient swallows it – look for frequent swallowing, blood on pillow,
  haemostasis or haemoptysis.
• Urgent escalation to a paediatric anaesthetist/ENT.
• Allow the patient to sit upright and encourage spitting blood out.
• Apply 100% oxygen if it does not cause distress to the child.
• Obtain IV access.
• Start resuscitation if any signs of shock are present.
• Take a history from the parents/paediatric team:
• Events since the procedure.
• Duration of bleeding.
• AMPLE history/review anaesthetic chart.
  *Allergies, medications, past medical history, last PO intake and events leading to presentation

Question 5

How would you assess this patient on the ward?

Continued…

Answer 5

Examination:
* General – GCS and signs of active bleeding.

• Airway.
• Focused respiratory and cardiovascular examinations including peripheral and central pulses, capillary refill and urine output.

Investigations:
* Respiratory rate and oxygen saturations.

• Heart rate and blood pressure (blood pressure is a less sensitive parameter due to the ability of paediatric physiology to compensate).
• Temperature.
• Bloods including haemoglobin, clotting and cross match.
• Bedside haemoglobin if available (haemocue or venous blood gas, which will give lactate, haemoglobin and mixed oxygen saturations – <70% is an indicator for increased morbidity and mortality).

Question 6

On examination the patient has a heart rate of 134 beats/minute, a blood pressure of 81/53 and a delayed capillary refill time. He is drowsy.

How would you manage this patient?

Answer 6

Resuscitation:
* Given the observations and signs of active bleeding, this patient is in hypovolaemic shock and requires urgent resuscitation prior to transfer and definitive management.

• Call for help – paediatric peri-arrest team and activation of the major haemorrhage protocol.
• Titrate oxygen delivery to saturations of 94%–98%.
• Intravenous access – at least two large bore cannulae (use intraosseous
  needle early if unsuccessful).
• Attach continuous monitoring.
• Administer 20 mL/kg fluid boluses of isotonic crystalloid over 5 minutes until blood is available; reassess the heart rate and blood pressure after each bolus and repeat if appropriate.
• Cautious suction if severe ongoing bleeding but care as it may disrupt any formed clots.

Question 7

How would you manage this patient?

Continued…

Answer 7

Preparation for surgery:
* Notify the theatre coordinator urgently in order to facilitate preparation of surgical and anaesthetic equipment.

• Notification of senior anaesthetic and ENT team, if not already contacted, and coordinate surgical and anaesthetic plans.

Transfer to theatre:
* Monitored transfer to theatre once stabilised with anaesthetist and ENT surgeon present in case of sudden airway obstruction or a major bleed.

Question 8

What are the options for induction of anaesthesia in this patient?

Answer 8

• Ensure parental consent, WHO checklist, AAGBI monitoring and check patency of intravenous access.
• Preparation for anaesthetic should include the presence of an experienced paediatric anaesthetist, trained assistant, availability of resuscitation/difficult airway trolleys and appropriate doses of routine and emergency drugs.
• Specific equipment should include a large bore nasogastric tube and two suction devices. Blood and blood products should be present in theatre. A smaller-sized endotracheal tube than normal may be required.
• Anaesthetise the patient in theatre with surgeons present and scrubbed.

Question 9

What are the options for induction of anaesthesia in this patient?

Continued…

Answer 9

Gas induction:
* Inhalational induction with sevoflurane in 100% oxygen.

• Maintenance of spontaneous ventilation.
• Induction can be done in the left lateral position and a slight head-down position to allow drainage of blood.
• The ongoing effort of breathing can help the anaesthetist identify the
  relevant anatomy if the airway is bloodied due to rhythmic upper airway movement and bubbles.

Question 10

What are the options for induction of anaesthesia in this patient?

Answer 10

Intravenous induction
* Rapid sequence induction with appropriate doses of induction agents, but care must be taken due to the risk of cardiovascular collapse.
* Appropriate induction agents would be ketamine (1–2 mg/kg) and
rocuronium (1 mg/kg).
* Gentle positive pressure ventilation due to the risk of aspiration.
* Titration of analgesia may be more difficult in paralysed patients,
especially those with OSA.

Other considerations
* Discuss the use of 10 mg/kg tranexamic acid with surgeon – there is weak evidence in post-tonsillectomy secondary bleeds for its use.
* Thorough suctioning of gastric contents to remove swallowed blood
once haemostasis is achieved, using a large bore orogastric tube.
* Rule out a nasopharyngeal clot (and risk of dislodgement with
postoperative airway instrumentation).
* Extubate awake in the left lateral position.
* A postoperative course of antibiotics, dexamethasone and adrenaline nebulisers may be required.