UBP 5.4 (Long Form): ENT – Bleeding Tonsil Flashcards
Would you use a Flexible LMA for this case?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Assuming the surgeon was comfortable working around the Flexible LMA and that this obese child with OSHS was able to maintain adequate spontaneous ventilation with only gentle assisted ventilation (peak inspiratory pressures less than 20 cm H2O), I would utilize a Flexible LMA, recognizing that this may be particularly beneficial in this patient with asthma.
While an ETT is easier to place and occupies less space in the oropharynx, the LMA provides better protection of the lower airway from blood, as compared to an uncuffed ETT, and is associated with less bronchospasm, laryngospasm, bleeding, and post-operative desaturation.
However, if I was unable to properly seat the LMA, or if this obese patient with OSHS was unable to maintain adequate spontaneous ventilation without positive pressure ventilation (which would place him at increased risk for gastric insufflation) I would place a cuffed endotracheal tube, recognizing that there is no evidence that the utilization of an LMA for adenotonsillectomy decreases morbidity when compared with an ETT.
You determine that it is acceptable to place an LMA.
However, his tonsils occupy more than 75% of the pharyngeal area, and you are struggling to properly place the device.
What measures can you take?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Recognizing that tonsillar enlargement can complicate the proper placement of an LMA,
the maneuvers I would employ to facilitate placement would include –
- increased head extension,
- anterior displacement of the tongue,
- lateral insertion of the LMA, and
- using my index finger to guide the tip of the LMA around the pharyngeal curve.
If these measures failed, I would consider using a laryngoscope to facilitate placement.
The case is completed without complication.
Assuming you successfully placed the LMA, when would you remove it?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
In the absence of obstructive sleep apnea, obesity, or difficult airway, it is acceptable to remove the LMA prior to emergence in children who are maintaining adequate spontaneous ventilation.
However, for this obese patient with OSHS, it would be more appropriate to remove the LMA as soon as the patient regained consciousness (opens his eyes to command), recognizing that awake children do not tolerate the presence of an LMA as well as do adults (this is why the LMA should not be utilized as an oral airway in children, and should be immediately removed with the return of consciousness), and further recognizing that there may be an increased risk of bronchospasm due to his asthma.
Therefore, since blood and secretions are often present in the oropharynx at the conclusion of surgery, I would leave the cuff inflated, gently suction the oropharynx with a soft flexible catheter, allow the child to regain consciousness, remove the LMA, apply 100% oxygen, and place him in the left-lateral position with his head slightly down (assuming this positioning did not cause upper airway obstruction in this patient with OSHS) to allow blood and secretions to drain down and out.
The patient goes home and returns the following day with bleeding.
He appears very anxious, his blood pressure is 104/58 mmHg, and the surgeon wants to proceed immediately to surgery.
What would you say?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Given the potential for significant blood loss and hypovolemia (i.e. occult blood loss into the stomach; inadequate fluid intake due to sore throat) in combination with impaired coagulation (hemophilia A), I would want to optimize this patient prior to proceeding to surgery.
- While his blood pressure is near normal, the catecholamine-induced vasoconstriction that occurs in response to blood loss may mask considerable hypovolemia, placing the patient at increased risk for profound hypotension with the initiation of anesthesia.
- Moreover, it would be helpful to know if inadequate factor VIII replacement were contributing to his bleeding.
Therefore, I would:
- provide 100% oxygen;
- order a hemoglobin, hematocrit, factor VIII activity level, and coagulation profile (in particular, an aPTT);
- type and cross the patient for 2 units of blood;
- evaluate the patient for physical signs of significant post-tonsillectomy hemorrhage, such as orthostatic hypotension, dizziness, excessive swallowing, tachycardia, increased capillary refill time, pallor, sweating, and restlessness;
- obtain large bore intravenous access;
- provide volume resuscitation and blood product replacement as indicated;
- provide a short acting B2-agonist (i.e. albuterol), to optimize his asthmatic condition;
- provide perioperative steroid supplementation, to avoid adrenal insufficiency in this patient who was recently treated with prednisone; and
- prepare for a difficult intubation (i.e. obesity, airway obstruction, bleeding, and pharyngeal edema).
Clinical Notes:
- Signs consistent with significant bleeding include:
- tachycardia, excessive swallowing, pallor, restlessness, increased capillary refill time, sweating, and airway obstruction.
- Dizziness and orthostatic hypotension are consistent with blood loss in excess of 20% of blood volume.
The PTT is normal, the hemoglobin is 7.0 mg/dL, and the surgeon says the procedure cannot wait for additional lab work.
Will you transfuse?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
While his normal PTT and hemoglobin level of 7.0 mg/dL would potentially suggest that the transfusion of blood products is unnecessary at this time, I would take into consideration the patient’s volume status and recent factor VIII levels before making a definitive decision about transfusion.
If he became unstable, his bleeding continued to be significant, or if I believed his hemoglobin level of 7.0 mg/dL represented a falsely elevated result secondary to hemoconcentration following a sore throat-induced reduction in fluid intake over the past day (best determined by history), I would consider transfusing 1-2 units of packed red blood cells.
Moreover, if after considering the time of his last infusion of factor VIII and his most recent factor VIII activity level I believed that his levels were below 100%, I would transfuse additional factor VIII concentrate.
Before you can obtain intravenous access, the patient vomits a substantial amount of blood into an emesis basin and begins spitting a considerable amount of bright red blood into a cup every few seconds.
The surgeon says we need to operate now!
Can’t you perform an inhalational induction and start the IV after induction?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
I would explain to the surgeon that I understand the urgency of the case, but that it would be inappropriate to proceed without intravenous access given the significant risk of cardiovascular depression during an inhalational induction in this patient who has experienced substantial blood loss.
Furthermore, an inhalational induction can be slow and risks the aspiration of blood with subsequent laryngospasm and/or compromised oxygenation.
Therefore, I would quickly obtain intravenous or intraosseous access and provide as much intravascular volume replacement as time allowed prior to inducing this patient.
You successfully place an IV catheter and begin volume resuscitation with blood products and crystalloids.
He continues to spit up a substantial amount of blood and his blood pressure drops to 88/52 mmHg.
What will you do?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
If I determined in consultation with the surgeon that the benefits of emergent surgery to control bleeding outweighed the benefits of additional volume resuscitation, I would:
- attempt to reduce bleeding by asking the surgeon to place a pharyngeal pack and compressing the ipsilateral carotid artery;
- proceed to the operating room with the patient and ensure the presence of difficult airway equipment, including two laryngoscopes and two large bore suction catheters;
- preoxygenate the child in the lateral and head down position to allow for the drainage of blood out of the mouth;
- reposition the patient supine and apply cricoid pressure;
- perform a rapid sequence induction utilizing succinylcholine, etomidate, and atropine;
- intubate the patient with a styletted and cuffed endotracheal tube to facilitate rapid intubation and minimize the risk of aspirating blood around the tube, respectively; and
- insert a gastric tube in an attempt to evacuate as much blood and food from his stomach as possible.
Moreover, I would be prepared to treat significant hypotension and/or bronchospasm, recognizing that the hemodynamic instability and the urgency of the case precluded complete volume resuscitation and the achievement of an adequate plane of anesthesia to reliably prevent bronchospasm in this asthmatic patient.
Following induction, his blood pressure drops to 74/40 mmHg and is not responding to phenylephrine.
What do you think may be going on?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Since his hypotension developed immediately following induction, the most likely cause is – an anesthesia-induced reduction in systemic vascular resistance combined with significant hypovolemia.
However, I would also keep in mind that the cardiodepressant effects of anesthesia combined with significant anemia may be a contributing factor, if not the primary cause of his hypotension.
Considering his chronic steroid therapy and the administration of blood products, I would consider the possibility of adrenal crisis secondary to insufficient perioperative steroid replacement and acute hemolytic transfusion reaction secondary to ABO incompatibility, respectively (ABO incompatibility is important for FFP, platelets, and packed red blood cells).
Moreover, if the patient had received FFP (to address blood loss or optimize his factor VIII activity), I would consider citrate-induced hypocalcemia.
Finally, recognizing the potential for an as yet undiagnosed neuromuscular disease in a child his age, I would consider the possibility of a succinylcholine-induced hyperkalemic response.
Following induction, his blood pressure drops to 74/40 mmHg and is not responding to phenylephrine.
What will you do?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
I would immediately:
- apply 100% oxygen, verify adequate ventilation, and auscultate the chest;
- evaluate the EKG to identify any signs of myocardial ischemia, hyperkalemia, hypocalcemia (citrate toxicity), and/or arrhythmia;
- reduce or turn off any volatile agent;
- continue aggressive intravascular volume replacement with crystalloids and/or blood products (given the lack of adequate preoperative volume resuscitation, it would be reasonable to assume hypovolemia);
- administer vasoactive agents as indicated; and
- recheck his hemoglobin level. Moreover, I would
- evaluate him for signs of acute hemolytic transfusion reaction (besides hypotension), such as elevated temperature, tachycardia, and hemoglobinuria.
- If he had received FFP, I would – check an ionized calcium level (normal = 1.1-1.4 mmol/L; 4.5-5.6 mg/dL) and
- evaluate the patient for signs of citrate-induced hypocalcemia (besides hypotension), such as prolonged QT interval, widened QRS complexes, flattened T waves, and narrow pulse pressure (elevated intraventricular end-diastolic pressure and central venous pressure may be noted with invasive monitoring).
- Finally, if the etiology of his hypotension remained uncertain and his hypotension proved unreponsive to all of my therapeutic interventions, I would – consider the possibility of adrenal insufficiency secondary to pituitary-adrenal axis suppression with chronic exogenous steroid administration.
If I suspected adrenal insufficiency were the cause, I would establish invasive monitoring (i.e. arterial line, central venous pressure line, pulmonary artery catheter), administer fluids and intravenous hydrocortisone, and correct any hypoglycemia, acidosis, and/or electrolyte abnormalities (i.e. hyperkalemia or hyponatremia).
How can prior treatment with exogenous steroids lead to Addisonian crisis in the perioperative period?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Prior treatment with exogenous steroids can lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis, resulting in adrenal atrophy and an inability to produce adequate cortisol under the physiologic stresses experienced during the perioperative period.
Cortisol plays an important role in catecholamine production and the synthesis, coupling, responsiveness, and regulation of B-receptors, thus affecting cardiac contractility, vascular permeability, and vascular tone.
While the normal daily production of cortisol is around 15-30 mg/day, under surgical stress the body produces 75-150 mg/day of cortisol (assuming no HPA axis suppression).
However, in the absence of adequate perioperative glucocorticoid replacement, a patient with HPA axis suppression will be – unable to produce adequate amounts of cortisol leading to – fever, abdominal pain, dehydration, nausea and vomiting, hypoglycemia (cortisol promotes gluconeogenesis, has anti-insulin effects, and inhibits peripheral utilization of glucose), acidosis, hyperkalemia, hyponatremia, circulatory collapse, and depressed mentation.
Clinical Notes:
Describe the Hypothalamic-Pituitary-Adrenal Axis.
Describe Common Steroid Replacement Regimens (in Adults).
Describe Pediatric Stress-Dose Steroid Recommendations (dosing is based on body surface area rather than kilograms).
Clinical Notes:
Hypothalamic-Pituitary-Adrenal Axis
- Corticotropin-releasing hormone (CRH) from the hypothalamus induces –> the production of adrenocorticotropic hormone (ACTH) in the pituitary gland, which, in turn, –> stimulates the adrenal glands to produce cortisol.
- Cortisol-induced negative feedback on the hypothalamus then reduces the production of CRH.
Common Steroid Replacement Regimens (Adults)
- 100 mg IV hydrocortisone preoperatively, followed by 100 mg every 8 hours on the day of surgery.
- 25 mg of IV hydrocortisone at induction, followed by 100 mg over the next 24 hours.
- Another type of regimen based on severity of surgery:
- Minor Surgery = 25 mg of IV hydrocortisone preoperatively, the day of surgery. No additional tapered dosing is required.
- Moderate Surgery = 50-75 mg of IV hydrocortisone preoperatively, on the day of surgery.
- Tapered dosing = 50 mg intraoperatively, followed by 20 mg every 8 hours on the first day, and returning to the patient’s usual dose on day 2.
- Severe Surgery = 100-150 mg of IV hydrocortisone preoperatively, on the day of surgery.
- Tapered dosing = 50 mg intraoperatively, followed by 25-50 mg every 8 hours for 2 days, and returning to the patient’s usual dose on day 3.
Pediatric Stress-Dose Steroid Recommendations:
- Degree of Surgical Stress / Dose:
- Minor: < 1 hr (eg, hernia) =
- Hydrocortisone 25 mg/m^2 IV
- Methylprednisolone 5 mg/m^2 IV
- Moderate: extremity surgery =
- Hydrocortisone 50 mg/m^2 IV
- Methylprednisolone 10 mg/m^2 IV
- Or usual oral dose and reduced parenteral dose
- Major: laparotomy =
- Hydrocortisone 25 mg/m^2 IV every 6 hr
- Methylprednisolone 5 mg/m^2 IV every 6 hr
- Wean over 1-3 days
How would you extubate this patient?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Given the risk of aspiration secondary to blood in the stomach and/or recent food ingestion, I would extubate him when awake with protective airway reflexes intact.
However, an awake extubation places him at increased risk for laryngospasm secondary to blood and debris in the oropharynx and/or bronchospasm secondary to his asthma.
Therefore, I would –
- attempt to empty his stomach with an orogastric tube;
- position the patient laterally to facilitate the movement of blood away from the vocal cords and out of the oropharynx;
- gently suction out the oropharynx with a soft flexible catheter;
- administer narcotics (the dose should be reduced to 1/2 the normal dose in children undergoing tonsillectomy for OSA), a B2-agonist, and intravenous lidocaine in order to blunt any airway irritation; and
- extubate him when awake with protective airway reflexes intact.
Post-operative Management:
How will you reduce the risk of post-operative nausea?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Recognizing that there is increased risk of post-operative nausea and vomiting associated with adenotonsillectomy (30-65%) (possibly due to the irritant effects of blood in the stomach or stimulation of the gag reflex secondary to inflammation and/or edema at the surgical site), I would attempt to reduce this risk by:
- ensuring adequate intravenous hydration until he resumed normal intake;
- utilizing propofol during induction;
- administering dexamethasone for its antiemetic and opioid sparing properties;
- decompressing the stomach utilizing an orogastric tube (gastric distension may trigger the emetic center); and
- giving ondansetron.
Moreover, since meperidine may be associated with an increased risk of nausea, I would avoid the use of this narcotic.
Post-operative Management:
Would you administer ketorolac for pain control?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Ketorolac is often used for post-adenotonsillectomy pain control, despite concerns about increased risk of bleeding.
However, given this patient’s hemophilia, I would NOT administer any drug that could further compromise coagulation, including platelet inhibitors such as ketorolac or aspirin.
Therefore, I would employ alternative methods of pain control such as – administering dexamethasone or acetaminophen.
I would also consider narcotics an acceptable option.
However, due to the increased risk of nausea, vomiting, and respiratory complications (children undergoing tonsillectomy for OSA are of particular concern in regards to respiratory depression due to an increased sensitivity to opioids), I would utilize the lowest effective dose, for as short a period as possible, on an as needed basis only.
Fortunately, the pain following surgical correction of a post-tonsillectomy bleeding is often LESS pronounced due to the limitation of surgery to the area of bleeding.
Clinical Notes:
- According to the 2014 ASA Guidelines for the perioperative management of patients with OSA:
- Children undergoing tonsillectomy for OSA may be more sensitive to opioids secondary to alterations in their mu-opioid receptors with repeated episodes of hypoxemia.
- It is recommended to utilize approximately half the usual dose of opioid.
- The FDA has administered a Black Box Warning in association with the use of codeine-containing products in children after tonsillectomy and/or adenoidectomy due to the risk of respiratory depression. They recommend utilizing the lowest effective dose for the shortest period of time on an as needed basis.
Post-operative Management:
Does the patient require additional doses of factor VIII, postoperatively?
- (An 8-year-old, 46 kg, male presents for tonsillectomy. He is receiving the tonsillectomy to relieve airway obstruction, although his sleep study demonstrated no apneic events. He has received factor VIII concentrate, preoperatively. The mother reports that her son has a history of asthma, and that he was given prednisone 8-9 weeks ago because his asthma was “acting up”.*
- PMHx: Asthma, Obstructive Sleep Hypopnea Syndrome (OSHS)*
- Anesth. Hx: Prolonged bleeding following a tooth extraction 3 years ago.*
- Meds: Albuterol*
- Allergies: NKDA*
- PE: Vital Signs: HR = 116, BP = 110/64 mmHg, RR = 14, Temp = 36.5 C.*
- Airway: Mallampati II*
- Lungs: CTA*
- CV: Regular rhythm, tachycardia*
- Labs: Hgb = 7.8 gm/dL; PT = 14 seconds; aPTT = 26 seconds; Factor VIII activity level = 95%)*
Recognizing that the half-life of factor VIII may be as short as 6 hours in children (6-10 hours in adults), and further understanding that the risk of post-tonsillectomy bleeding ranges from 1-8% (depending on the age of the child and the surgical technique employed), I would recommend continued factor VIII replacement for up to 2 weeks (4-6 weeks of replacement therapy may be required for bone or joint surgery).
The patient’s levels should be monitored closely, –
- maintaining levels of 75-100% for the first 24-48 hours,
- 30-50% until the risk of bleeding is past (about 10 days, post-tonsillectomy), and
- 10-20% for the remainder of the 2 weeks.
Clinical Notes:
- 75% of post-tonsillectomy hemorrhages occur within the first 6 hours.
- The majority of the remaining 25% occur within the first 24 hours.
- Primary bleeding, occurring within the first 24 hours, is generally more serious than secondary bleeding.
- Secondary bleeding, due to contraction of the eschar covering the tonsillar bed, may occur for up to 10 days.
