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Manegment of major bleeds

  • Early intubation of any major post tonsillectomy bleed should be considered for airway protection
  • Return to OT for ligation of bleeding vessel
  • Electrocautery, chemical cautery
  • Suture ties
  • Suture tonsillar pillars together for persistent oozing
  • Arterial bleeding may require angiographic embolisation or external carotid ligation
  • Blood transfusion

Other potential risk factors for haemorrhage

  • NSAIDs - inhibit platelet aggregation and prolong bleeding time.
  • Non significant increase in risk of bleeding needing surgical intervention OR 1.69 (0.71-4.01)
  • No alteration of risk of bleeding managed conservatively OR 0.99 (0.41-2.40)
  • Reduce vomiting RR 0.72 (0.61-0.85)
  • Recent acute tonsillitis
  • Weight <15kg
  • Older age

Post tonsillectomy Haemorrhage

Bleeding disorders

  • Von Willebrands disease - mutated vWF causes abnormal platelet function and low factor VIII activity
  • Mx: Tranexamic acid, vasopressin, recombinant factor VIII
  • Haemophilia - deficiency of F VIII (type A) or F IX (type B)
  • Mx: Recombinant factor VIII, vasopressin (mobilises factor VIII), tranexamic acid

Need closer observation for a longer duration

Epidemiology

Surgical technique

From the UK/Ireland audit:

  • 3.5% had post op haemorrhage
  • 0.6% primary haemorrhage (within 24 hours of surgery)
  • 3% secondary haemorrhage (>24 hours after surgery, usually 5-10 days)

From Uptodate:

  • Primary haemorrhage 0.2-2.2%
  • Secondary haemorrhage 0.1-3% - caused by premature separation of the eschar due to underlying infection or dehydration
  • 29% of bleeds required OT
  • (UK audit) Cold steel + ties vs bipolar diathermy - increased risk with bipolar OR 2.47 (1.81-3.36)
  • (Cochrane review) Dissection vs diathermy - mean 21.56mL less blood loss with diathermy, no difference in post op bleed rates.
  • Coblation - similar risk of primary bleeding RR 0.99 (0.48-2.05), possible increased risk of secondary bleeding RR 1.36 (0.95-1.95)
  • Haemostatic glues - no statistical difference compared to electrocautery

Vascular Anatomy

  • Inferior pole - tonsillar artery (branch of the facial artery)
  • Branches from ascending palatine, lingual, descending palatine and ascending pharyngeal arteries
  • External palatine vein (paratonsillar vein) - descends from the soft palate and passes close to the lateral surface of the tonsil before it enters the pharyngeal venous plexus

Initial measures

  • Airway protection
  • Apply pressure to tonsillar bed with gauze
  • Inject lignocaine/adrenaline
  • Cauterize with silver nitrate
  • Observation
  • IV line, check haemoglobin, group and crossmatch
  • ?Tranexamic acid

References

  • Yuen S, Kawai K, Roberson DW, and Murray R. Do post-tonsillectomy patients who report bleeding require observation if no bleeding is present on exam? Int J Pediar Otorhinolargol. 95. 75-79 2017 Apr.
  • Pynnonen M, Brinkmeier J, Thorne M, Chong LY, Burton M. Coblation versus other surgical techniques for tonsillectomy. The Cochrane Library. Aug 2017.
  • Sproat R, Radford P, Hunt A. Haemostatic glues in tonsillectomy: A systematic review. Largynoscope. 126(1): 236-42, 2016 Jan.
  • Pinder DK, Wilson H, Hilton MP. Dissection versus diathermy for tonsillectomy. Cochrane Database of Systematic Reviews. 2011, 3 Art. No.:CD002211.
  • Lewis S, Nicholson A, Cardwell M, Siviter G, Smith A. Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. The Cochrane Library. July 2013.
  • https://www-clinicalkey-com-au.ezproxy.surgeons.org/#!/content/book/3-s2.0-B9780702044199000039?scrollTo=%23hl0002001
  • Lowe D, Van der Meulen J, Cromwell D, Lewsey J, Copley L, Browne J, Yung M, Brown P. Key Messages from the National Prospective Tonsillectomy Audit. Laryngoscope. 117(4) 717-724. April 2007.
  • Uptodate - Tonsillectomy (with or without adenoidectomy) in children: postoperative care and complications.
  • Uptodate - Tonsilectomy in adults

Bleeding - clinical features to look for

  • Alteration in vital signs
  • Active bleeding
  • Clot in the fossa
  • Hx of bleeding but normal exam - ?admit for observation: 11% subsequently need cauterization, 84% of those bleed within 24 hrs of presentation
  • Signs of infection (febrile, raised inflammatory markers - antibiotics
  • Drop in haemoglobin
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