Tonsillectomy is one of the most common procedures performed in children. Post op hemorrhage is either primary (within 24 hours) or secondary/delayed ≥24 hours. Primary hemorrhage is more rare and is seen in 0.2-2% of cases. Secondary hemorrhage is a bit more common, especially in the Emergency Department as kids have been home for several days. rates vary, but estimates settle around 3%. It most commonly occurs between 5-10 days post-op, with the median 6th POD. The cause is separation of the eschar – which may be precipitated by dehydration, vomiting or rarely infection. Most stop on their own, but rarely they can lead to calamitous bleeding and airway compromise – so it is obviously a good idea to take them seriously.
Certainly kids with existing bleeding disorders are more likely to have hemorrhage, as as those that have had a tonsillectomy for chronic tonsillitis as opposed to obstructive sleep apnea. This is probably due to preexisting and ongoing scarring causes by chronic infection. Since minor bleeding may herald severe bleeding a visit to the ED is always recommended. With that in mind, here is a sample protocol for assessing and managing post-op tonsillectomy hemorrhage.
Identify post tonsillectomy bleeding. This includes:
- Clot in the pharynx
- Bloody emesis
- Oozing from the tonsil
Place an IV and obtain labs:
- CBC with diff
Consider the following based on the protocols in your institution and local practice:
- Von Willebrand’s Factor (vWF) – Note that the vWF can be falsely elevated (normal) in the setting of an acute bleed, thus all patients should see their PCP in 1 month to have a vWF repeated.
- Thrombin Time
Patient’s in shock, or with an arterial bleed should definitely get a type and screen or type and cross.
Though patients may be anxious and uncomfortable avoid over-sedating them so as to impair airway protective responses. Consider IV and rectal acetaminophen and fentanyl.
Call ENT ASAP. Tell them the salient details including post op day, site and estimate of rate of bleeding and cardiovascular status of patient. Have equipment ready. Many hospitals (like mine) have a “tonsil tray” or “ENT tote” readymade.
Generally, an otolaryngologist at the bedside will:
- Remove/suction clots from the tonsil beds
- Apply pressure for at least 5 minutes to active bleeding sites – generally with tonsil sponge with epinephrine / pontacaine mix (1:1)
- If residual bleeding is still present apply silver nitrate – contact time to bleeding site should be limited to <5 seconds. Patients can gargle with ice water in between applications – this presents mucosal burns from leftover silver nitrate. Reapplication of silver nitrate (up to 3 times at my institution) is done to persistent sites.
- If bleeding is still active then patient should be prepared to go to the operating room. These patients will be admitted afterwards.