FRCA Notes

Post-Tonsillectomy Bleed

Resources

  • Post-tonsillectomy bleeding can be classified as either:
    • Primary - within 24hrs of surgery
    • Secondary - from 24hrs to 28 days post-operatively

  • The incidence of primary post-tonsillectomy bleeding is in the region 1 - 4%; it is the commonest in-hospital complication
  • Secondary post-tonsillectomy bleeding is less common, with an incidence of <1%
  • Post-tonsillectomy bleeding is typically venous in origin
Arterial supply Venous drainage
Ascending pharyngeal artery Tonsillar capsule venous plexus
Lesser & ascending palatine arteries Lingual vein
Tonsillar artery Pharyngeal venous plexus
Dorsal lingual artery
Facial artery


Surgical risk factors

  • Surgical technique has come under the microscope with respect to post-tonsillectomy bleeding
    • The Cochrane bods found no robust evidence a coblation technique increases risk of primary post-tonsillectomy bleeding
    • It may, however, slightly increase risk of secondary post-tonsillectomy bleed

  • An inexperienced surgeon during the initial surgery increases risk of bleeding

Patient risk factors

  • Age >6yrs increases rate of secondary bleeding
  • Perhaps counter-intuitively, presence of abnormal coagulation doesn't appear to increase risk
  • Obesity does not increase risk

Airway

  • Anticipate a difficult airway on account of:
    • Blood loss obscuring laryngoscopic view
    • Risk of aspiration of regurgitated blood or post-operative oral intake
    • Airway oedema from recent airway instrumentation/surgery

Other considerations

  • Hidden blood loss and risk of hypovolaemia
  • Patient has recently had a GA
  • Potential for undiagnosed coagulation disorder
  • Patient anxiety/distress

Post-tonsillectomy bleeds are an emergency and I would seek senior anaesthetic support as well as making a rapid but thorough assessment of the patient

  • An ABCDE approach and 100% oxygen first-off
  • The patient should be managed à la major haemorrhage:
    • Wide-bore IV access
    • Urgent bloods: group & cross-match, clotting profile, FBC, U&E, venous gas, point-of-care Hb and visco-elastic haemostatic assay
    • Prompt resuscitation with crystalloid or blood
    • Consider TXA
    • Ensure normothermia

Airway management

  • Take note of previous ETT size and grade of intubation
  • Have smaller-sized ETT available
  • Anticipate and plan for a difficult airway (see above); reported incidence of difficult intubation ~3%
  • Requires two suction catheters in use, one each side with a dedicated person for suction
  • May require VL and extra light source
  • Use small doses of induction agent and consider using suxamethonium
  • The most common complication during induction is transient hypoxia (up to 10%); gentle bagging post-induction as part of a modified RSI technique can reduce this

Induction choices

  • Two techniques are described, each with their own (de)merits:
    1. Inhalational technique with head down + lateral position
    2. RSI
Inhalational (lateral) RSI
Drains blood from airway via gravity Reduces risk of aspiration
Allows pre-oxygenation during induction Use of NMBA makes intubating conditions optimised
May be difficult in anxious child Less stressful for child
Deep volatile anaesthesia risks CV instability in already hypovolaemic patient Difficult to adequately pre-oxygenate, esp. if anxious child
Risk of aspiration/laryngospasm May inflate stomach, increasing aspiration risk
Unfamiliar technique Absence of spontaneous ventilation during induction increases risk of hypoxaemia

Extubation

  • NG tube insertion and aspiration of blood (clots) from stomach prior to extubation
  • Thorough suctioning of upper airway
  • Extubate wide awake
  • Extubate head down and left lateral

  • Require at least 24hrs admission post-surgery due to risk of re-bleeding