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A 10-year-old female presents to the emergency room with a history of spitting blood-tinged secretions for 2 days and vomiting blood in the last 12 hours. The patient’s past surgical history is significant for having had an adenotonsillectomy done 8 days earlier.

Upon examination, patient is sitting in bed, anxious. Vitals: HR 120/min; BP 100/50; respiratory rate 24/min.

Labs: HCT 30%; platelets 220K/μL; INR 1.2.


Posttonsillectomy bleeding is a common complication following adenotonsillectomy. Bleeding can be primary; this occurs within the first 24 hours after surgery in <1% of the patients. Secondary bleeding occurs between 5 and 12 days after surgery in about 4% of the patients and may be due to sloughing of the eschar from the tonsillar bed, loosening of ties, or infection from underlying chronic tonsillitis.

Most of the blood is swallowed; therefore, it is difficult to estimate the amount of blood loss. The patient may be hypovolemic due to blood loss or have poor oral intake due to pain and bleeding. There may be an underlying coagulopathy that is still undiagnosed at the time of presentation.

There is a potential for difficult intubation because of difficulty in visualizing the larynx secondary to bleeding obscuring the view and edema from the previous surgery. Patients are at risk for pulmonary aspiration because of the presence of large amounts of sequestered intragastric blood at the time of the induction of anesthesia.


  • Use awake IV placement.

  • Use preoxygenation with rapid sequence induction with cricoid pressure with propofol or etomidate and succinylcholine or rocuronium.

  • Have two suctions available in case one clots while you are trying to intubate.

  • Intubate with an oral Ring-Adair-Elwyn cuffed endotracheal tube.

  • Maintain with volatile agents + IV narcotics.

  • Intraoperative blood transfusion may be required.

  • Once hemostasis is achieved, suction the stomach with a large-bore nasogastric tube.

  • Extubate the patient when fully awake and place the patient in a left lateral position.


Patients are monitored in the postanesthesia care unit after extubation for any signs of bleeding or hemodynamic instability and are admitted to the floor postoperatively. They are discharged home when there is no further sign of bleeding, and have resumed eating, drinking, and their pain is well controlled.

DOs and DON’Ts

  • ⊗ Do not try suctioning the stomach prior to induction.

  • ✓ Do place a large-bore IV for hydration and volume resuscitation.

  • ⊗ Do not attempt inhalation induction.

  • ✓ Do send a type and cross for blood and know about blood availability prior to starting the case.


A tonsillectomy can be either partial or total and can be either intracapsular or extracapsular. Different surgical techniques are used to perform tonsillectomy; ...

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