What advice to give ER when they call about a post tonsillectomy bleed.
1) Obtain IV access and triage bleed severity
- H&P, EBL
- CBC
- Type & screen
- Consider PT/PTT
- Administer nebulized TXA - you can give nebulized TXA and IV TXA simultaneously
- Airway management and transfusion as indicated
- ENT consult early
2) If active bleeding noted, clot present in tonsillar fossa, or non-active bleed with > 1 cup EBL:
- Lean pt forward
- Consider IV TXA
- Hold direct pressure pending ENT evaluation for brisk bleeds
- If bleed resolves, observe minimum of 3 hours since last bleed
- D/C vs In-Hospital observation - shared decision with ENT on call MD
3) If not actively bleeding, no clot in tonsillar fossa:
- Observe 3 hours since last bleed
- Consider d/c after ENT Consult if clinically stable, no further bleeding, and no abnormalities on labs
4) On Discharge from the ER:
- Consider oral Amicar prescription X 10 days
- Avoid NSAIDs for 14 days
- Return to the ER for repeat bleeding
- Arrange ENT f/u per institutional/surgeon practices
Otolaryngology Protocol for Post Tonsillectomy Hemorrhage.
1) If active bleeding, clot in tonsillar fossa, or non-active bleed with > 1 cup EBL:
- Evaluate on initial presentation and consider need for urgent operative intervention
- Consider bedside suctioning of unstable clots if appropriate (low-volume, non-active bleeds, cooperative age-appropriate child) to facilitate high-quality exam
- Consider bedside cautery if > 12 years old and able to visualize bleeder well
2) If hemorrhage recalcitrant to TXA after 20 minutes, recurrent bleeding, clinical concern, or bleeding brisk/uncontrolled:
- Transport to the OR for surgical management
- If hemorrhage is brisk, hold firm pressure while preparing/transporting to the OR
3) If not actively bleeding, no clot in tonsillar fossa:
- Evaluate on initial presentation
- Trial of nebulized TXA and observation: you can give both nebulized and IV TXA simultaneously
- Observe 3 hours since last bleed
- May consider discharge vs in-hospital observation if clinically stable, no further bleeding, and no abnormalities on labs
4) On Discharge:
- Consider oral Amicar prescription X 10 days
- Avoid NSAIDs X 14 days
- Return to ER for repeat bleeding
- Arrange ENT f/u per institutional/surgeon practices
Intracapsular tonsillectomy and post operative bleeding/hemorrhage
1) Intracapsular tonsillectomy is the only tonsillectomy technique that has been shown to result in lower rates of post-tonsillectomy hemorrhage (Sedgwick et al. 2023).
2) This should be weighed against the need for revision surgery, particularly in patients with recurrent tonsillitis, as well as the resource utilization associated with intracapsular techniques.
3) There is o/w no consensus regarding whether specific instrumentation or techniques have the lower rates of post-tonsillectomy hemorrhage.
Tranexamic Acid (TXA)
1) TXA is an antifibrinolytic agent that can be used prophylactically prior to surgery or after after trauma/surgery
2) Epsilon-aminocaproic acid (EACA) and Tranexamic acid (TXA) are small molecular weight pharmacologic agents that are widely used to inhibit fibrinolysis.
- They bind to the lysine attachment site of the plasminogen molecule to prevent its binding to fibrin and its conversion to plasmin, thereby inhibiting fibrinolysis
3) TXA is the most widely used and extensively studied antifibrinolytic agent
- TXA is 10 times more potent that EACA
- TXA is available for topical administration to inhibit local fibrinolysis at the site of bleeding
- Oral TXA is also available
4) Dosing of TXA
- Typically 10 to 30mg/kg of IV TXA is administered as an initial loading dose, followed by an infusion of 1 to 16mg/kg per hour during cardiopulmonary bypass
5) Potential side effects of TXA
- Thrombosis - theoretical risk, but not seen in practice
- Seizures with high doses of TXA
- Wrong site administration - there can be severe side effects if given intrathecally (similar appearance of ampules of TXA and Hyperbaric Bupivacaine)
Post Tonsillectomy Bleeding: Primary vs Secondary
1) Primary post tonsillectomy hemorrhage: bleeding that occurs withing the first 24 hours after surgery
- Risk of primary hemorrhage = 0.1% to 1%
2) Secondary post tonsillectomy hemorrhage: bleeding that occurs after 24 hours, often on POD 5-10
- Generally caused by sloughing of primary eschar as the tonsil be heals
- Risk of secondary hemorrhage = 1.5% to 4.3%
Preoperative screening of Pediatric patients for increased risk of post-operative hemorrhage
ISTH/SSC Bleeding Assessment Tool
Rodeghiero F. Tosetto A. Abshire T, et al; ISTH/SSC joint VWF and Perinatal/Pediatric Hemostasis Subcommittee Working Group. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost. 2010 Sep;8(9): 2063-5. doi: 10.1111/j.1538-7836.2010.03975x. PMID: 20626619
Amicar (Epsilon-Aminocaproic Acid/EACA)
1) Oral form:
- Tablets: 500mg, 1000mg
- Solution: (0.25g/mL)
2) Administration: For the treatment of acute bleeding syndromes due to elevated fibrinolytic activity
- Give 5 Amicar 1000mg tabs (5 grams) or 10 Amicar 500mg tabs (5 grams) or 20 mL of Amicar Oral Solution (5grams) during the first hour of treatment, followed by a continuing rate of 1 Amicar 1000mg tablets or 2 Amicar 500mg tablets (1gram) or 5 mL of Amicar Oral Solution (1.25grams) per hour
- This dosage should be continued for 8 hours or until the bleeding has been controlled
Analgesia after post tonsillectomy hemorrhage
1) To reduce risk of rebleed, avoid NSAID use until complete recovery
- 14 days after the last bleed
2) Risks and benefits of opioid analgesia and extension of post-procedure steroid courses should be considered in the context of individual comorbidities
3) Celecoxib is a reasonable alternative to Ibuprofen for non-opioid analgesia in post-tonsillectomy hemorrhage patients
What are the criteria for transfusion in post tonsillectomy hemorrhage?
1) Hgb < 7
2) Hgb < 8 and ongoing bleeding or symptomatic anemia
3) Hgb < 10 with ongoing heavy bleeding
When should you consult Hematology in post tonsillectomy hemorrhage?
1) Known bleeding/coagulation d/o
2) Abnormal bleeding history
3) Need for transfusion
4) Recurrent post tonsillectomy bleeding
5) Score >/= 4 on ISTCH-SCCC Bleeding assessment tool
- https://bleedingscore.oerte.nl/
Tranexamic Acid and Amicar Dosage
1) Neblized:
- </= 25kg: 250mg Q 20 minutes up to 3X
- > 25kg: 500mg Q 20 minutes up to 3X
2) Intravenous:
- 10mg/kg (maximum of 1000mg) Q8 hours
3) Oral Amicar Dosage:
- Amicar 100mg/kg loading dose, then 50mg/kg Q6 hours
What are the precautions/contraindications to systemic antifibrinolytic use?
1) Absolute contraindications
- H/O anaphylaxis with same agent
2) Relative contraindications (use with caution, consider risk-benefit profile of systemic TXA):
- Inherited or induced hypercoagulability (including oral contraceptive use)
- Pregnancy (category B)
- History of arterial or venous thrombosis
- Renal insufficiency
- History of a seizure d/o
Post Tonsillectomy Hemorrhage - Miscellaneous
1) Soak a tonsil pack in Afrin and apply to the tonsillar fossa for active bleeding
2) Things to do in the ER prior to my arrival
- Two large bore IVs and give IV fluids
- Labs: CBC, PT/PTT/ Type and screen
- Give nebulized and IV TXA
- Hold direct pressure on tonsil bed
