Franklin B. Chiao
A 5-year-old boy with history of obstructive sleep apnea (OSA) has blood in his mouth after a tonsillectomy and adenoidectomy 4 hours ago. He appears pale and uncomfortable. His heart rate is about 140 beats per minute, his blood pressure is 66/30 mm Hg with a mean arterial pressure of 38 mm Hg, the pulse oximeter reads 99%, and his respiratory rate is 28 breaths per minute.
A. Medical Disease and Differential Diagnosis
What is in your differential diagnosis?
What are the development stages of tonsillar growth? What nerves innervate the tonsillar region? What is the vascular anatomy of the tonsils?
What are your immediate concerns if it is a bleeding tonsil?
Does age matter for risk of bleeding? What other risk factors are there?
What is the morbidity and mortality of post-tonsillectomy hemorrhage?
B. Preoperative Evaluation and Preparation
How will you assess this patient? What are important physical exam findings?
What additional steps would you take to assess and manage hemorrhage? Does the patient need an arterial or central venous line?
What anesthesia preparation should begin in the operating room for this patient?
What factors would influence your decision to use vasopressors?
Would you premedicate this patient?
Once the laboratory results are completed, how would they be interpreted?
What would you expect from the surgeon?
How do you address parental concerns about anesthesia-related neurotoxicity? What evidence is there for adverse impacts? What would you tell the parents about this?
C. Intraoperative Management
What is your induction plan? Would you perform a rapid sequence induction or mask inhalational induction?
How would one plan for suctioning the blood in the oropharynx?
What is your airway management plan? Should an experienced laryngoscopist be involved?
Once in the airway, there is poor visualization in the presence of blood in the oropharynx. What maneuvers may help identify the glottic opening?
What supplemental medications would you plan to use during the case?
Assuming the surgery is completed without any adverse events, what would be your extubation plan, if any, at this point?
D. Postoperative Management
Does this patient require an intensive care unit (ICU) setting?
How would you transport this patient?
What are some potential postoperative complications? What if the patient had stridor and a hoarse cry?
What do surgeons often tell their patients before being discharged?
A. Medical Disease and Differential Diagnosis
A.1. What is in your differential diagnosis?
Blood in the oropharynx could have several etiologies. Given his recent tonsil surgery, postoperative bleeding from the surgical site is a major concern. Other etiologies include a uvular injury or postoperative hematemesis. Epistaxis may be a sign of nasopharyngeal trauma or the usual epistaxis in a patient with a history of nasal bleeding.
Salem A, Healy S, Pau H. Management of spontaneous tonsillar bleeding: review. J Laryngol Otol. 2010;124:470-473.
A.2. What are the development stages of tonsillar growth? What nerves innervate the tonsillar region? What is the vascular anatomy of the tonsils?
Tonsils grow rapidly until age 5 or 6 years. By puberty, they usually reach their maximum size of 10 to 15 mm by 20 to 25 mm. With aging, the reactive lymphoid tissue atrophies. The tonsillar area is innervated by branches of the maxillary and glossopharyngeal nerves.
Sources of bleeding can be arterial, venous, or involve vascular anomalies. The arterial blood supply comes from several branches of the external carotid artery. The main sources often consist of the ascending pharyngeal artery, descending palatine artery, ascending palatine artery, facial artery branches, and dorsal lingual artery. Venous return is to the peritonsillar plexus, the lingual vein, and the pharyngeal plexus.
Standring S, Borley NR, Collins P, et al, ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th ed. Edinburgh, Scotland: Churchill Livingstone Elsevier; 2008:566-567.
A.3. What are your immediate concerns if it is a bleeding tonsil?
Post-tonsillectomy hemorrhage is a surgical emergency. Undue delay in treatment has resulted in catastrophic complications. There may be a limited initial vascular spasm and vasoconstriction from catecholamine release that reduces bleeding for a short time. If there is active bleeding, the surgeon must be alerted, and often the child must return to the operating room immediately. “Primary” bleeding occurs within 24 hours in about 1% of tonsillectomy patients, and secondary bleeding occurs in up to 4% of these patients and usually happens in the 2 weeks following surgery. Spontaneous hemorrhage is also possible. Peripheral vessels are usually the source, but erosion into vessels of the carotid sheath may occur.
The major anesthetic challenge is to secure the airway obscured by a blood-filled oropharynx in a hypovolemic and anemic patient.
Gardner JF. Sutures and disasters in tonsillectomy. Arch Otolaryngol. 1968;88:551-555.
Windfuhr JP, Chen YS, Remmert S. Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients. Otolaryngol Head Neck Surg. 2005;132(2):281-286.
A.4. Does age matter for risk of bleeding? What other risk factors are there?
The incidence of post-tonsillectomy bleeding increases with age, particularly after age 10 years. Other risk factors include a history of recurrent tonsillitis, multiple bleeding episodes, and coagulopathies. There are cases of unsuspected vascular anomalies. It is not clear whether the choice of anesthetic technique for the initial tonsillectomy surgery makes any difference, such as awake versus deep extubation and endotracheal tube (ETT) versus laryngeal mask airway, in the incidence of postsurgical bleeding (Fig. 45.1).
Tomkinson A, Harrison W, Owens D, et al. Risk factors for postoperative hemorrhage following tonsillectomy. Laryngoscope. 2011;121:279-288.
A.5. What is the morbidity and mortality of post-tonsillectomy hemorrhage?
Although most post-tonsillectomy bleeding is handled successfully, the potential for serious adverse outcomes including death from post-tonsillectomy bleeding cannot be understated. There are cases of emergent tracheotomies, hypoxic brain injury, and death from hemorrhage, aspiration, or airway obstruction. Autopsies confirmed these findings and have also found wound necrosis. One particular risk factor for mortality is a history of repeated bleeding episodes. Inpatient stay would seem to mitigate the risk, but when bleeding is brisk, there is sometimes still not enough time to return to the operating room. Post-adenoidectomy bleeding is also possible, but it is much more rare and milder.
Windfuhr JP. Lethal post-tonsillectomy hemorrhage. Auris Nasus Larynx. 2003;30:391-396.
Windfuhr JP, Schloendorff G, Sesterhenn AM, et al. A devastating outcome after adenoidectomy and tonsillectomy: ideas for improved prevention and management. Otolaryngol Head Neck Surg. 2009;140:191-196.
B. Preoperative Evaluation and Preparation
B.1. How will you assess this patient? What are important physical exam findings?
The key questions for the preoperative assessment are the following: Is the patient able to maintain his airway, is bleeding active, and is the patient conscious?
Hypovolemia, anemia, aspiration risk, and difficult laryngoscopy are major anesthetic concerns. Hypotension is a late sign of hypovolemic shock. Dizziness and orthostatic hypotension also indicate the need for more aggressive resuscitation. Given this patient’s tachycardia and hypotension, he is probably hypovolemic.
Physical exam focuses on evaluating the airway and the patient’s volume status. After examination of the airway, one should also look at a previous anesthetic record to see the intubation note. The presence of dry mucous membranes, poor skin turgor, or sunken orbits indicate volume depletion. Weighing of a diaper in babies or looking at urine output measurements helps assess fluid status as well.
Fields R, Gencorelli F, Litman R. Anesthetic management of the pediatric bleeding tonsil. Paediatr Anaesth. 2010;20(11):982-986.
Gregory GA, Andropoulos DB, eds. Gregory’s Pediatric Anesthesia. 5th ed. Chichester, United Kingdom: Wiley-Blackwell; 2012:786.
B.2. What additional steps would you take to assess and manage hemorrhage? Does the patient need an arterial or central venous line?
An intravenous catheter must be placed preoperatively for fluid resuscitation, and blood for laboratory tests should be drawn. The team should start fluid resuscitation to replace blood loss. It is prudent to check hemoglobin, hematocrit, platelets, prothrombin time (PT)/international normalized ratio (INR), and partial thromboplastin time (PTT) values. If the hemoglobin level is low and/or the bleeding profuse, administration of packed red blood cells seems appropriate.