9.4 Bleeding Tonsil

Question 1

You have been called to see a 5-year-old child who had a tonsillectomy 6 hours previously. The child is bleeding and needs to go back to theatre for haemostasis. When you arrive on the ward, the child is agitated and says he feels sick. The postoperative blood loss is reported to be minimal by the nursing staff.

On examination:

Looks pale
Pulse: 125/min
Respiratory rate: 25/min
Blood pressure: 70/30 mmHg
Capillary refill time: 4 seconds

What are the specific problems in this case?

Answer 1

• Hypovolaemia/hypotension
• Risk of aspiration due to swallowing of blood
• Difficult intubation secondary to laryngeal oedema and bleeding
• A second general anaesthetic
• Management of an anxious child and parents
• Bleeding diathesis

Question 2

What are the types of post-tonsillectomy bleeding?

Answer 2

The incidence of bleeding following tonsillectomy is 0.5%–2% depending
upon the surgical technique.

• Primary—
  this may occur within 24 hours of surgery.
• Secondary—
  this may occur up to 28 days post-surgery and is
  associated with sloughing of the eschar (dead tissue) overlying the
  tonsillar bed, loosened vessel ties, or infection from underlying chronic
  tonsillitis.

Question 3

Blood loss quantity + quantifying

Answer 3

• The presenting signs relate to the quantity of blood loss.
• Blood loss is secondary to venous or capillary ooze from the tonsillar
  bed.
  It may be difficult to measure, as bleeding may occur over several
  hours and large amounts of blood may be swallowed.
  Brisk bleeding may lead to the child spitting blood.
  The child may be hypovolaemic with low haemoglobin.
• Tachycardia, tachypnoea, delayed capillary refill, and decreased
  urine output are early indicators of hypovolaemic shock, whereas
  hypotension and altered sensorium are late signs of hypovolaemia, with
  decompensated shock.
• The cardiovascular status is assessed by considering cardiovascular
  parameters as well as perfusion of other organs:

Question 4

Signs of blood loss by vitals

Answer 4

Heart rate—this child may be tachycardic due to anxiety, but this may also
be due to catecholamine release to maintain cardiac output in the presence
of hypovolaemia. Bradycardia is caused by acidosis and hypoxia and is a
preterminal sign.

Capillary refill time—hypovolaemia leads to a poor skin perfusion and
prolonged capillary refill time (> 2 seconds). Mottling, pallor, and peripheral
cyanosis are also indicators of poor skin perfusion.

Blood pressure is difficult to measure, especially in younger children.
Hypotension is a late sign of hypovolaemic shock.

Tachypnoea may be due to anxiety but also occurs in response to acidosis
secondary to poor tissue perfusion and severe anaemia.

Core/skin temperature difference of more than 2°C is an important sign of
shock.

Decreased or absent urine output—Poor urine output (< 1 mL/kg/h in
children, and < 2 mL/kg/h in infants) indicates inadequate renal perfusion

Question 5

How would you commence resuscitation?

Answer 5

• Resuscitation should be with isotonic crystalloid
  (0.9% Saline or Hartmann’s solution),
  colloid, or blood; intravenous boluses of fluid,

20 mL/kg stat, repeated if necessary after reassessment
of the cardiovascular system.

Large volumes of fluid may be required (40–60 mL/kg).

Hypotonic fluids such as 5% dextrose, 0.18% saline,
and 2.5% dextrose or 0.45% saline and 5% dextrose must not be used
in the acute resuscitation of hypovolaemic children.

Question 6

How would you anaesthetise this child?

Answer 6

There is some debate about the safest technique of anaesthesia for a
bleeding tonsil. The two common choices are:

1. Inhalational induction in the head down, lateral position.
2. Modified intravenous rapid sequence induction with cricoid pressure.

The pros and cons of each technique are discussed below.

Question 7

Inhalational induction
Pros

Answer 7

Pros:
Inhalational induction is a technique that is familiar to anaesthetists,
and oxygenation is well maintained during spontaneous ventilation.

Inhalational induction in the lateral position helps drain blood from the airway
by means of gravity, and clots can be gently suctioned from the airway once
an adequate depth of anaesthesia is achieved.

Suxamethonium may be given prior to intubation,
either with the child remaining on his or her side or
turned into the supine position and cricoid pressure applied.

Question 8

Cons: Inhalational induction

Answer 8

Cons: Inhalational induction with a volatile agent in an anxious child who is
bleeding can be difficult.

Deep anaesthesia may be induced inadvertently,
particularly in a child recovering from anaesthesia a few hours earlier.

Deep anaesthesia is a risk factor for cardiac arrest in a child who may still
be hypovolaemic.

Intubating in the lateral position is unfamiliar to most anaesthetists,

and many would turn the child into the supine position prior to intubation.

Question 9

Intravenous rapid sequence induction Pros:

Answer 9

Pros:
Anaesthesia can be induced in the supine position with the application
of cricoid pressure to reduce the risk of aspiration.

The use of muscle relaxants helps produce ideal conditions for intubation.

Intravenous induction is less stressful for the child who should already have an intravenous cannula in situ.

Question 10

Intravenous rapid sequence induction

Cons:

Answer 10

Cons:

A modified rapid sequence induction is required as it is impossible
to adequately preoxygenate an anxious child who is bleeding;

facemask ventilation will be required after the administration of suxamethonium.

Care must be taken not to inflate the stomach during facemask ventilation,

as this will encourage regurgitation and aspiration.

There is a risk of hypoxia if intubation is difficult and spontaneous respiration has been lost.

Question 11

What steps should be taken intraoperatively?

Answer 11

During the operation, further fluid and blood should be given as guided by
clinical monitoring—heart rate, capillary refill, core-peripheral temperature
difference, and blood pressure.

Near patient testing using a Hemocue® or the WHo haemoglobin scale,
if available, can guide transfusion requirements.

The child may become cold during surgery due to large volume transfusion.

The child should be kept well covered to maintain body temperature and, if
possible, a warming blanket used with temperature monitoring. Hypothermia
may exacerbate coagulopathy.

Once haemostasis is achieved, a large-bore gastric tube should be passed
under direct vision to empty the stomach.

Nondepolarising neuromuscular blockade should be reversed.

The trachea should be extubated with the child fully awake in the left lateral, head-down position.

Alternatively, particularly in the absence of a tipping trolley, the ‘tonsil’ position may be
used, where a bolster is placed under the child’s chest in the lateral position
so that the head is below the level of the chest and fluids drain from the
mouth.

Question 12

What postoperative care should be taken?

Answer 12

Postoperatively it is important to monitor the child closely in a well-lit area
(do not return them to a dark ward area at night),

with regular observation of vital parameters.

Blood transfusion may need to be continued in recovery.

The haemoglobin should be measured and coagulation screen sent if
possible.

Minimum haemoglobin of 8 g/dL is acceptable provided there is no
further bleeding.

The child will require iron supplements for the next 6 weeks if this is the case.