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CASE PRESENTATION

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A 6-year-old boy with Down syndrome is en route to your children's hospital by ambulance with post-tonsillectomy bleeding.

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He underwent adenotonsillectomy under general anesthesia 22 hours earlier. Despite being overweight at 37 kg and enlarged adenoids, he did not suffer from obstructive sleep apnea. Prior to his surgery, the child was uncooperative necessitating an inhalational induction with some struggling. Venous access was difficult even post-induction requiring several attempts, and finally being achieved in the left saphenous vein at the ankle. Because of possible atlanto-occipital instability associated with Down syndrome, cervical spine (C-spine) precautions were implemented during airway management. Bag-mask-ventilation with an oropharyngeal airway was easy. Direct laryngoscopy revealed a Grade 3 Cormack/Lehane (C-L) view of the larynx due to an enlarged tongue. Indirect laryngoscopy was then attempted using the GlideScope which revealed a Grade 1 view C-L. The trachea was intubated with an uncuffed 5.0-mm ID oral RAE tube. Adenotonsillectomy was performed uneventfully, and the child was discharged home after an overnight observation period.

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While at home, the boy ate a hard tea biscuit, leading to onset of immediate sharp pain with intra-oral bleeding.

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The child is in the emergency room sitting on a stretcher and spitting blood frequently into a kidney basin. The child is in moderate distress with the following vital signs: HR 152 bpm, BP 97/57 mm Hg. The child does not tolerate nasal prong oxygen and the pulse oximeter reading is 94% on room air. Auscultation of the chest is clear. Examination of the mouth reveals brisk bleeding in the right tonsillar bed. An attempt to start an intravenous line in the right saphenous vein was unsuccessful. However blood samples are obtained for a CBC, coagulation parameters, and a cross match. The child is then transferred to the operating room (OR) for further management.

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INTRODUCTION

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What Is the Incidence, Morbidity, and Mortality of Pediatric Post-Tonsillectomy Bleeding?

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Tonsillectomy is one of the most frequently performed surgical procedures in children, with approximately 580,000 outpatient pediatric adenotonsillectomies performed annually in the United States.1 The most common post-tonsillectomy complications are postoperative nausea and vomiting (PONV) and pain. Dehydration may occur in children due to delayed poor oral intake, nausea, and fever. Delayed postoperative bleeding is the most significant complication and is not uncommon.2,3 Many estimates of the incidence of post-tonsillectomy bleeding exist in the literature, varying widely from 0% to 11.5%.4 Typically, however, the rate ranges between 2.9% and 3.4%.5,6 Mortality rates from severe bleeding are rarely reported in the literature.14 Two large studies reported an incidence of mortality of 0 out of 15,996 and 1 out of 16,381 tonsillectomies in 1979 and 1970, respectively.7 Sixty-seven percent of post-tonsillectomy bleeding originates in the tonsillar fossa and 27% in the nasopharynx. There are two major time frames for postoperative bleeding. Most often ...

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