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CASE PRESENTATION

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

He underwent adenotonsillectomy due to recurrent throat infections under general anesthesia 22 hours earlier. Despite being overweight at 37 kg and enlarged adenoids, he did not suffer from obstructive sleep apnea (OSA) or obstructive sleep-disordered breathing. Prior to his surgery, the child was uncooperative necessitating an inhalational induction. Intravenous access was difficult requiring several attempts and finally was successful in the left saphenous vein. Because of possible atlanto-occipital instability associated with Down syndrome, cervical spine (C-spine) precautions were implemented during airway management. 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 C-L view. The trachea was intubated with an uncuffed 5.0 mm ID oral Ring Adair Elwyn tube. Adenotonsillectomy was performed uneventfully, and the child was discharged home after an overnight observation period. While at home, the boy ate a tea biscuit, leading to the onset of immediate sharp pain with intraoral bleeding.

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 mmHg. 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 of 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 complete blood count, coagulation parameters and a cross-match. The child is then transferred to the operating room (OR) for further management.

INTRODUCTION

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

Tonsillectomy is one of the most frequently performed surgical procedures in children, with approximately 580,000 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%.3 Typically, however, the rate ranges between 0.2% and 4.8%.4–6 Mortality rates from severe bleeding are rarely reported in the literature. They range from 1 in 10,0007 in earlier studies to less than 1 in 100,000 in recent publications.8 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 the bleeding occurs within the first 24 hours after surgery (primary bleeding).9...

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