Anesthesia for Post-

Tonsillectomy and
Adenoidectomy
Hemorrhage
Robin G. Cox, MBBS, MRCP(UK), FRCA, FRCPC
Professor of Anesthesiology
University of Calgary
Calgary Alberta Canada

Updated 4/2017
Disclosure
• No conflicts of interest to declare
Objectives
To describe the epidemiology of post-tonsillectomy
and adenoidectomy hemorrhage in children
To discuss the causes of post-tonsillectomy and
adenoidectomy hemorrhage in children
To formulate a plan for anesthesia management of
the child with a post-tonsillectomy and
adenoidectomy hemorrhage:
Preoperative assessment and optimization
Intraoperative management
Postoperative management
Epidemiology of Post-Tonsillectomy
Hemorrhage in Children
• National Prospective Tonsillectomy Audit
• 277 UK hospitals
• 33,921 patients undergoing tonsillectomy
• 21,060 were < 16 years of age
• Overall hemorrhage rate 3.5 %:
• Primary (< 24 hrs postoperatively) 0.55 %
• Secondary (> 24 hrs postoperatively) 3.0 %
• Both 0.07 %
• Return to O.R. in 0.93 %
(Lowe, Laryngoscope 2007)
 Epidemiology of Post-
Adenoidectomy Hemorrhage
• Surgical Instrument Surveillance Programme
(Wales)
• 5,588 patients undergoing adenoidectomy:
• 4,225 with tonsillectomy (median age 6.1 yr)
• 1,363 sole procedure (median age 6.3 yr)
• Return to O.R. for adenoid bleeding in 22 (0.4 %)
• All cases of adenoid bleeding occurred within 24
hrs, unlike tonsillectomy, which more often
presents with secondary hemorrhage

(Tomkinson, Laryngoscope 2012)

 Mortality after Tonsillectomy
and Adenoidectomy
• Mortality fortunately rare, but it still occurs:
• 1:7,000 – 1:170,000
• 32 deaths reviewed (31 tonsil; 1 adenoid)
• Mortality more common in secondary hemorrhage
• Aberrant course of internal carotid artery a rare factor
• Deaths commonly related to airway obstruction and
aspiration of blood
• Rigid instruments for endoscopy and suction may
have prevented death in some of these patients

(Windfuhr, ORL 2013 & Otolaryngol Head Neck Surg 2009)

 Aberrant Internal Carotid
Artery - risk of 1°
Hemorrhage

Straight Curved Kinked Coiled

May be close to tonsil bed

(Paulsen, J Anat 2000)

 Risk Factors for Hemorrhage
• Older aged patients
• In some studies:
• Males
• Recurrent tonsillitis and peritonsillar abscess
• Inadequate hemostasis (primary)
• Excessive use of electrosurgery/coblation (secondary)
• Use of NSAIDs
• Underlying coagulopathy is a very rare cause
• Use of Dexamethasone is NOT a risk factor
(Tomkinson, Sarny, Laryngoscope 2011; Mowatt, Clin Otolaryng 2006;
Baugh, Otolaryngol Head Neck Surg 2010;
Geva, Otolaryngol Head Neck Surg 2011)
 Risk Factors for Hemorrhage:
Effect of Age
• Tonsillectomy or adenotonsillectomy most
commonly performed in first decade of life
• Patients ≥ 12 years of age are 1.5 times more likely
to experience early postoperative hemorrhage
requiring surgery than those < 12 years of age
• Patients ≥ 12 years of age are 3.3 times more likely
to experience late postoperative hemorrhage
requiring surgery than those < 12 years of age

(Tomkinson, Laryngoscope 2011)

 Risk Factors for Hemorrhage:
Effect of NSAIDs
 Ketorolac RCT 1996 INCREASED RISK

 Systematic Review 2003 AMBIGUOUS

 Meta-analysis 2003 INCREASED RISK

 Cochrane Review 2005 NO INCREASED RISK

(Splinter, Can J Anes 1996; Møiniche, Anesth Analg 2003;

Marret, Anesthesiology 2003; Cardwell, Cochrane Collaboration 2005)
 Methods to Reduce Risk
• Effective methods:
• Screening for bleeding disorders in the history
• Surgical technique avoiding excessive cautery
• Avoiding surgery on acutely inflamed tonsils

• Ineffective:
• Routine preoperative screening for coagulopathy
• Routine use of antibiotics

(Lowe, Laryngoscope 2007)

 Methods to Reduce Risk:
Role of Tranexamic Acid?
• Tranexamic Acid (TXA), a fibrinolytic agent, has
been shown effective in reducing blood loss in
cardiac and orthopedic surgery.
• Systematic review and meta-analysis suggests that
TXA may reduce the amount of blood loss during
tonsillectomy, but not the incidence of
postoperative hemorrhage.
• Larger, more rigorous, studies are required to
evaluate the possible role of TXA in the prevention
of postoperative hemorrhage.
(Robb, J Laryngol Otol 2014)
 Management of Post-
Tonsillectomy Hemorrhage
• Non-operative (73%):
• Observation
• Packs, epinephrine, cautery (in older cooperative
children)
• Operative (27%):
• Cautery
• Ligation of bleeding points
• Rarely more invasive measures (embolization, ligation of
external carotid artery)

(Lowe, Laryngoscope 2007)

Post-Tonsillectomy
Hemorrhage
Preoperative Management
• Assessment:
• Must be a rapid evaluation, combined with resuscitation
as required
• Remember routine preoperative questions
• Review clinical course following surgery, estimate degree
of bleeding (however blood loss may be hidden)
• Review anesthesia record of tonsillectomy, including
postoperative medications
• Focus on airway, vital signs and cardiovascular status
Preoperative Management
• Initial Resuscitation:
• Apply oxygen and obtain intravenous access
• Bolus with Normal Saline or Ringers Lactate – 10 ml/kg
repeated as required
• Send blood for CBC, coagulation studies, and blood
typing and screen, crossmatch as required
• [Hb] may not be reliable in assessing degree of
hemorrhage
• Transfuse for [Hb] < 70 - 80 g/L
• In major hemorrhage, order FFP and platelets; consider
tranexamic acid
Preoperative Management
• Continuing Resuscitation:
• Evaluate response to fluid bolus
• Vital signs
• Capillary refill
• Mental status
• Remember that surgical control of the bleeding is part of
the resuscitation
• It may not be possible to achieve perfect vital signs
before induction of anesthesia
Intraoperative Management:
Induction
• Airway – could it be difficult?
• Hemodynamic State – hypovolemia, overt or
hidden?
• Full Stomach – must be assumed…
• Previous Sedation – particularly if anesthesia that
day
A Safe Method of Induction
• Adequate assistance and surgeon in the O.R.
• Two suction devices to hand and turned on to
maximum (Yankauer)
• Rapid sequence induction with preoxygenation and
cricoid pressure
• Induction agent:
• Choice of agent and dose according to hemodynamic
status – always assume there is major blood loss
• Muscle relaxant:
• Succinylcholine unless contraindicated
A Safe Method of Induction
• As soon as succinylcholine takes effect, perform
direct laryngoscopy, suction pharynx, and intubate
with oral RAE tube. GlideScope as backup, if
available
• Consider cuffed tube
• Suction ETT if any possibility of tracheal aspiration of
blood
• Recheck vital signs and continue volume loading as
required
• Allow the surgeon to proceed as soon as possible
 Induction Methods
• 475 children who underwent surgery for post-
tonsillectomy hemorrhage were retrospectively
reviewed
• Induction types were:
• 84.4% RSI
• 5.5% modified RSI
• 3.2% mask inhalation
• 0.2% tracheostomy
• 6.1% unspecified

(Fields, Pediatric Anesthesia 2010)

 Induction Methods
• Muscle relaxants used were:
• 88% succinylcholine
• 8% nondepolarizing muscle relaxant
• 3% no muscle relaxant, or unrecorded
• Atropine was used in 21.9% (atropine or
glycopyrrolate)
• Cricoid pressure recorded in 90%
• Only 2/475 patients encountered a difficult
intubation, requiring a second attempt.

(Fields, Pediatric Anesthesia 2010)

 Hypoxemia (n = 475)

Clinical Time Point SpO2 < 90% SpO2 < 80%

Induction &
12 2
Intubation

Intraoperative 6 1

Emergence &
22 6
Extubation

PACU 1 0

(Fields, Pediatric Anesthesia 2010)

Anesthetic Technique (cont.)
• Continuing resuscitation with fluid/blood products
• Coagulopathies are rare unless massive transfusion
• Caution with volatile agents (hypovolemia)
• Opiate dose reduced, particularly in primary
hemorrhage – may have opiates on board
• Empty stomach with large-bore tube under direct
vision
• Antiemetics - Dexamethasone/Ondansetron
• Awake extubation
Recovery Period
• Close monitoring for recurrent bleeding,
hemodynamic instability, airway obstruction
• Repeat hematology/coagulation studies as required
• Caution with sedative agents
• Surgeons may consider antibiotics in secondary
hemorrhage
Special Situations:
Induction if MH Susceptible
• Can proceed with RSI using large dose of
rocuronium (1.2 mg/kg)
• Consider remifentanil (1-2 µg/kg) as an alternative
to rocuronium, but be prepared to treat
bradycardia
• Ketamine, nitrous oxide both safe
• Maintain with TIVA
• Extubate awake
Special Situations:
Previously Difficult Airway
• E.G. Pierre-Robin Sequence
• Although spontaneous ventilation may be preferred
until the airway is secure, the classic inhalational
induction, in the head down lateral position, still
carries the risks of aspiration and hypotension
• GlideScope may be very effective and provide a
better view than fiberoptic techniques (blood)
• Surgeon skilled at rigid bronchoscopy and surgical
airways immediately available
Conclusions
• Prevention includes evaluating for bleeding
diathesis by history and investigation if indicated,
avoidance of excessive use of cautery/coblation,
and avoiding operating on acutely inflamed tonsils
• Perioperative management is focused on timely
resuscitation, an anesthetic technique that captures
the airway rapidly, continued resuscitation, and
very close postoperative monitoring
• With this approach, morbidity and mortality should
be very rare
References
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Browne J, Yung M, Brown P. Key messages from the National
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24.
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Postoperative hemorrhage following adenoidectomy.
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B. A devastating outcome after adenoidectomy and
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