Post-Tonsillectomy Bleeding – Anesthetic Considerations

Post-tonsillectomy bleeding is a serious and potentially life-threatening complication requiring prompt recognition and management. It can lead to airway compromise, aspiration, hypovolemia, and even cardiac arrest if not managed appropriately.

1. Classification of Post-Tonsillectomy Bleeding

✅ Primary bleeding occurs during surgery or immediately post-op and is usually arterial.

✅ Secondary bleeding occurs after eschar separation and is usually venous.

2. Risk Factors for Post-Tonsillectomy Bleeding

Patient-Related Risk Factors✅ Age >10 years (Higher risk than younger children)

✅ Males > Females

✅ Bleeding disorders (e.g., von Willebrand disease, hemophilia, thrombocytopenia)

✅ Use of NSAIDs, aspirin, or anticoagulants

✅ History of peritonsillar abscess or recurrent tonsillitis

Surgical Factors

✅ Cold dissection vs. Electrocautery vs. Coblation

• Cold dissection → Higher risk of primary bleeding

• Electrocautery → Risk of delayed bleeding due to thermal necrosis

• Coblation (radiofrequency ablation) → Lower bleeding risk but slower healing

✅ Inadequate intraoperative hemostasis

✅ Use of local vasoconstrictors (adrenaline infiltration)

3. Clinical Presentation of Post-Tonsillectomy Bleeding

Early Signs (Mild Bleeding)

✅ Blood-stained saliva or clots in the mouth

✅ Complaints of a metallic taste in the mouth

✅ Repeated swallowing (especially in a sleeping child – suggestive of ongoing bleeding!)

Severe Bleeding (Life-Threatening)

✅ Hematemesis (vomiting bright red blood or coffee-ground emesis due to swallowed blood)

✅ Hypovolemic shock: Tachycardia, hypotension, pallor, altered consciousness

✅ Airway compromise: Laryngospasm, aspiration, respiratory distress

⚠️ Children may not show hypotension until >30% blood loss! Early signs = Tachycardia, restlessness.

4. Emergency Management of Post-Tonsillectomy Bleeding

A. Prehospital / Initial Hospital Management

✅ Positioning: Keep the child sitting up and encourage spitting out blood (not swallowing).

✅ Vital Signs: Monitor HR, BP, SpO₂, RR (watch for shock).

✅ IV Access: Large bore IV cannula (18G or 20G in children) for fluid resuscitation.

✅ Fluids: Crystalloids (RL or NS), blood transfusion if needed.

✅ Oxygen supplementation – if airway compromise is suspected.

B. Airway Management

✅ Bleeding tonsillar bed → Suction the oropharynx (risk of aspiration).

✅ Avoid Blind Intubation!

✅ If severe bleeding → Plan for RSI with full stomach precautions (due to swallowed blood).

✅ Rapid Sequence Induction (RSI) protocol:

• Suction: Immediate post-intubation suctioning of the airway.

⚠️ In case of difficult intubation, prepare for surgical airway (tracheostomy or cricothyroidotomy).

C. Surgical Management

✅ Re-exploration in the operating room under GA.

✅ Electrocautery or suture ligation of bleeding vessel.

✅ Packing the tonsillar fossa with oxidized cellulose (Surgicel) or Floseal (Thrombin-gelatin matrix).

✅ Antibiotics if infection is suspected.

5. Postoperative Care After Re-exploration

✅ ICU monitoring for airway obstruction, aspiration risk, or re-bleeding.

✅ Strict fluid balance monitoring.

✅ Continue IV fluids, blood transfusion if required.

✅ Pain control: IV Paracetamol ± Opioids (avoid NSAIDs initially).

✅ Monitor for secondary bleeding (repeat eschar sloughing can occur).

6. MCQs on Post-Tonsillectomy Bleeding

1. The most common time for primary post-tonsillectomy bleeding is:

A) 30 minutes post-op

B) Within 6 hours

C) Within 24 hours

D) 5-10 days after surgery

✅ Answer: C (Primary bleeding occurs within 24 hours).

2. The most common time for secondary post-tonsillectomy bleeding is:

A) Within 24 hours

B) 5-10 days post-op

C) 2 weeks post-op

D) Immediately post-extubation

✅ Answer: B (Secondary bleeding occurs after eschar sloughing).

3. The best way to manage a child presenting with severe post-tonsillectomy bleeding is:

A) Give oral tranexamic acid

B) Perform blind nasal intubation

C) Secure IV access, fluid resuscitation, and RSI with ETT placement

D) Keep the child supine and wait for bleeding to stop

✅ Answer: C (Airway control and fluid resuscitation are critical).

4. Which anesthetic agent is preferred for induction in a bleeding tonsillectomy patient?

A) Propofol

B) Ketamine

C) Sevoflurane

D) Midazolam

✅ Answer: B (Ketamine preserves airway reflexes and hemodynamic stability).