Bleeding tonsils
Tonsillectomy is the commonest operation performed in the UK, and, each year, >50 000 tonsillectomies are carried out. In 2005, the National Prospective Tonsillectomy Audit published data on 33 921 patients who underwent a tonsillectomy between July 2003 and September 2004. Children aged <5 years accounted for 23%, children aged 5–16 years for 49%, and 16 years or over for 28% of all tonsillectomy procedures. The aim of the audit was to investigate the occurrence of haemorrhage and other complications in the first 28 days after tonsillectomy.
The National Prospective Tonsillectomy Audit is the largest audit undertaken for tonsillectomy and described the primary and secondary tonsillar haemorrhage rates. Primary complications occurred during the initial stay and delayed discharge, and required a return to theatre or a blood transfusion. Secondary complications required readmission to hospital within 28 days of the initial surgery.
In 33 921 patients, 95% recovered uneventfully, whilst 0.9% required a return trip to theatre. The remainder suffered less severe complications such as mild bleeding, pain, or vomiting. There were 1197 (3.5%) complications involving either a primary or secondary tonsillar haemorrhage, and 318 (0.9%) patients required a return to theatre within 28 days of their initial operation. Of these, 150 (0.4%) patients were returned to theatre during their initial hospital stay, whilst 176 (0.5%) patients were returned to theatre during a readmission.
Adults had higher haemorrhage rates than children. The highest haemorrhage rates were seen in patients with quinsy (5.4%). Patients with a pharyngeal obstruction had a lower rate of haemorrhage than patients with recurrent acute tonsillitis (the most common indication for surgery).
1 Recognize the signs and symptoms of post-tonsillectomy haemorrhage
2 Deliver appropriate resuscitation prior to surgical intervention
3 Discuss anaesthetic techniques for emergency operative management of a patient with bleeding tonsils.
2A07; 2D01; 2D02; 2D04
A healthy 7-year-old child was scheduled for a routine tonsillectomy for recurrent acute tonsillitis on an elective ear, nose, and throat (ENT) morning operating list. The child had a previous general anaesthetic for dental clearance of damaged teeth 1 year ago, with no complications and an uneventful recovery at home. The tonsillectomy procedure had been postponed on two previous occasions because of an active acute tonsillitis.
On this occasion, the child had finished a course of antibiotics prescribed by the GP 2 days prior to admission. Preoperative assessment revealed a fit and healthy 7-year-old boy with large tonsils. Preoperative oral paracetamol and diclofenac were given 1 hour before surgery. Following IV induction with fentanyl and propofol, flexible LMA insertion, and spontaneous ventilation, general anaesthesia had been uneventful. Large tonsillar tissues were resected, and <10 mL of blood had been lost intraoperatively, and IV fluids were continued into the post-operative period. Recovery was uneventful, and observations were normal, following which the child was returned to the ward.
Five hours later, the nursing staff on the ward have asked for an ENT and anaesthestic review of the child. There has been no obvious blood loss from the mouth, but the child has vomited once, is occasionally spitting out blood, and is not eating, and the nursing staff are concerned, because he looks very tired.
Although there is no obvious blood loss from the mouth, significant blood can still be lost and swallowed over several hours following a tonsillectomy. The child has vomited on one occasion, and this was reported as containing blood. This child is not eating and complains of feeling sick, and the parents have noticed that he seems to be constantly swallowing which suggests there may be significant bleeding and swallowing of blood. Oxygen should be administered but may not be tolerated.
Primary haemorrhage is usually within the first 6 hours post-operatively but can present immediately in the recovery area. The bleeding is usually as a result of venous or capillary oozing from the tonsillar bed. Secondary haemorrhage is within 28 days of the initial surgery and can be as a result of vessel ties coming loose, sloughing, or infection of the tissue overlying the tonsillar bed.
It is not possible to identify the amount of blood lost, because much of it is swallowed, and therefore hypovolaemic assessment and resuscitation are clinical.
Early indicators of significant bleeding and hypovolaemia are:
◆ Tachycardia: an increased HR is the principal physiological response to hypovolaemia
◆ CRT (>2 s): hypovolaemia resulting in reduced skin perfusion
◆ Mottling, pallor, and peripheral cyanosis: hypovolaemia resulting in reduced skin perfusion
◆ Temperature: a difference of >2°C between the core temperature and skin temperature
◆ Tachypnoea: in response to metabolic tissue acidosis secondary to tissue hypoperfusion
◆ Urine output: reduced urine output secondary to hypovolaemia and renal hypoperfusion.
Late indicators of significant bleeding and hypovolaemia include:
◆ BP: hypotension is a late sign
◆ Reduced conscious level/GCS: altered consciousness level is a late sign.
Severe indicators of massive blood loss and hypovolaemia include:
◆ Bradycardia: a reduced HR in the presence of severe hypovolaemia is a preterminal sign requiring immediate treatment.
On examination, the child has a HR of 145, CRT of 3 s, RR of 28 breaths/min, and BP of 83/38 mmHg; he looks pale and has cool peripheries and periods of agitation and sleeping.
Significant bleeding has occurred; the child is hypovolaemic and requires immediate resuscitation and then transfer to theatre.
Resuscitation is usually with isotonic crystalloid or colloid in the first instance, because blood is usually not immediately available. Hypotonic fluids should not be used. Hartmann’s solution or 0.9% saline are suitable crystalloid solutions. Blood is given as soon as it is available. The response to an initial bolus dose of 20 mL/kg is assessed clinically by various indicators of hypovolaemia: HR, CRT, skin perfusion, temperature, and tachypnoea.
More fluid may be required and is administered after repeated assessment of the clinical signs. General anaesthesia should follow resuscitation, avoiding the potential catastrophic cardiovascular complications after induction of general anaesthesia in a hypovolaemic child.
After 35 mL/kg of fluid, the child has a HR of 95, CRT of 2 s, RR of 21 breaths/min, and BP of 84/43 mmHg; he looks pale. Blood has been taken for coagulation screening and cross-matching, and blood is now available. Coagulation screening results are not yet available. A decision is made to take the child to the operating theatre.
Although the general anaesthetic 5 hours previously was uneventful, a second general anaesthetic on a resuscitated child will be more challenging, requiring an experienced anaesthetist. Senior anaesthetic and surgical help should be sought and may well be needed.
◆ Full stomach: this may be because the child has eaten and drunk fluids after the operation on the ward before bleeding has been recognized or, more commonly, as a result of swallowed blood
◆ Difficult intubation: any child with a bleeding tonsil should be treated as a patient with a full stomach and will require tracheal intubation. The original procedure may have been performed with a tracheal tube or with a flexible LMA. If the child had been intubated, a record of the ease of direct laryngoscopy and tracheal intubation will be present. Irrespective of the ease of the previous laryngoscopy and tracheal intubation, all children have the potential to convert from an easy laryngoscopy and intubation to a difficult intubation. It can often surprise the novice how quickly a normal airway can convert to a difficult airway in the presence of blood, clots, and bleeding, and as a result of the swelling and oedema secondary to surgical and anaesthetic instrumentation. Precautions for a potential difficult intubation should be taken
◆ Parental anxiety: both parents and child will be anxious. Expectations of a routine day case procedure will have transformed to a bleeding child, requiring resuscitation and an emergency operation.
In addition to all standard equipment for an emergency, preparations for a potentially difficult intubation should be made. This might include a selection of direct laryngoscope blades, video laryngoscopes, and tracheal tubes of various sizes. Typically, a smaller tracheal tube may be required because of associated swelling and oedema, and, on initial placement, this may become blocked with clots and blood. A second tracheal tube of a similar size may be needed.
Following placement of a tracheal tube, swallowed blood should be suctioned from the stomach after the insertion of wide-bore orogastric tubes. Standard orogastric feeding-type tubes are not suitable for suctioning large amounts of blood from the stomach, because they are easily blocked. At the end of the operation, the stomach should be suctioned again before extubation.
Either technique can be used, and the final decision will depend on the experience of the anaesthetist. The chosen technique is the one they are most experienced in and feel comfortable with. The surgeon should be scrubbed and prepared in case of difficulty with the tracheal intubation.
◆ RSI: this involves a rapid sequence intubation with cricoid pressure, as appropriate. Preoxygenation is attempted but may not be tolerated by an anxious bleeding child, and gentle ventilation may be necessary after the administration of muscle relaxants and before tracheal intubation. This technique allows laryngoscopy in a more familiar supine position under optimal intubating conditions with muscle relaxation
◆ Inhalational induction: this, in a child with a bleeding airway, is challenging. It can be a slow process and may lead to a deep plane of anaesthesia with cardiovascular instability. The left lateral position allows blood, clots, and secretions to drain away from the airway but makes laryngoscopy and tracheal intubation more difficult, because most anaesthetists are unfamiliar with laryngoscopy and tracheal intubation in a lateral position. To optimize laryngoscopy and tracheal intubation, some anaesthetists will turn the child into a supine position and may administer muscle relaxants.
Further fluid resuscitation, careful monitoring, and the administration of blood products may be necessary, guided by Hb assessment.
Standard surgery monitoring should include temperature measurement, active warming with blankets and fluid, eye protection, and peripheral nerve monitoring. At the end of the procedure, residual neuromuscular blockade is reversed, and the child extubated awake in a left lateral head-down position or in the ‘tonsil’ position, which places a pillow under the child’s lateral chest, which allows any residual blood or secretions to drain away from the airway.
Following extubation, careful observations should be continued in the recovery area. Further bleeding may still occur, and the repeat tracheal intubation and surgery may result in further swelling and oedema. Careful observations of the airway, cardiovascular and respiratory status, and Hb level should be made. Once the child appears stable, they can be transferred to a high dependency area on the ward where careful observations must be continued overnight.
Summary
More than 50 000 tonsillectomies are performed each year in the UK, with a tonsillar haemorrhage rate of 3.5%. Of these, 0.4% required a return to theatre during their initial hospital stay, and 0.5% returned to theatre during a readmission. Principles in the management of bleeding tonsils include the recognition of the signs and symptoms of post-tonsillectomy haemorrhage, appropriate resuscitation prior to surgical intervention, recognition of a full stomach, and the potential for a difficult intubation. Following the placement of a tracheal tube, swallowed blood should be suctioned from the stomach after the insertion of wide-bore orogastric tubes, and, following surgery, careful observations of the airway, cardiovascular and respiratory status, and Hb level should be made.