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A 6-year-old-boy with Down syndrome is on his way to the children's hospital by ambulance with post-tonsillectomy bleeding.

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He underwent adenotonsillectomy because of recurrent tonsillitis and enlarged adenoids under general anesthesia the day before, some 22 hours ago. Despite being overweight at 37 kg and enlarged adenoids he did not suffer from sleep apnea. Prior to his original surgery, the child was uncooperative necessitating an inhalation 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, laryngoscopy was performed with cervical spine (C-spine) precautions. Direct laryngoscopy presented a Grade 3 view due to an enlarged tongue. Bag-mask-ventilation with an oropharyngeal airway was easy throughout the preintubation phase. Indirect laryngoscopy using the GlideScope® revealed a Grade 1 view followed by the placement of a styletted, uncuffed 5-mm ID oral RAE tube. Adenotonsillectomy was performed in the usual fashion and the child was discharged home after an uneventful 20 hour overnight observation period.

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Apparently, while momentarily unattended at home, the boy ate a hard tea biscuit. The child immediately experienced a sharp pain and an intra-oral bleeding started.

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The emergency physician on duty is confronted with an overweight boy, 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 will 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 is not successful, but blood is obtained for a CBC, coagulation parameters, and cross match for blood. The child is then transferred to the operating room (OR).

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45.2.1 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. Rates in children aged 0 to 14 vary considerably within and between countries. In 1998, they varied from 19 per 10,000 children in Canada to 118 per 10,000 in Northern Ireland, so a very common procedure in both countries.1

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The most common post-tonsillectomy complications include postoperative nausea and vomiting and pain. Dehydration may occur in children due to delayed and poor oral intake, nausea, and fever. Delayed postoperative bleeding is the most significant complication and though uncommon, is not rare.2 Many estimates of the incidence of post-tonsillectomy bleeding exist in the literature varying widely from 0% to 11.5%.3 Typically, however, the rate ranges between 2.9% and 3.4%.4 Mortality rates are rarely reported in the literature. Two large studies reported 0 out of 15,996 and 1 out of 16,381 tonsillectomies in 1979 and 1970, ...

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