What are the risk factors that may contribute to multiple hemorrhages following tonsil surgery in children?
Bottom line: Multiple hemorrhages after tonsillectomy/tonsillotomy are uncommon. Age >12 years and high BMI for age may be associated with increased risk of rebleeding.
Background: A primary concern of pediatric tonsillectomies is post-tonsillectomy hemorrhage (PTH), as secondary effects, including airway obstruction and cardiovascular collapse, may be life threatening, especially in young children. Certain factors associated with PTH are well reported (older age, male sex, use of monopolar cautery, chronic infection, hot tonsillectomies), but there is a lack of data on risk factors of multiple bleeding episodes.
Study design: Retrospective chart review of 452 pediatric patients who experienced one or more PTH following tonsillectomy/tonsillotomy, with or without adenoidectomy, between 2010 and 2016 at a single, tertiary-care hospital.
Setting: Boston Children’s Hospital.
Synopsis: Of the 452 patients, 32 had multiple bleeding episodes; this constituted 7.1% of all patients with an initial bleed and 0.3% of all patients who had tonsil surgery. Among patients with multiple hemorrhages, the first occurred an average of 5.0 days and the second 8.9 days after the initial tonsil surgery; the mean number of days between first and second bleed was 3.9 days. Estimated blood loss and evidence of intraoperative blood transfusions did not suggest that subsequent bleeds were significantly more severe than initial hemorrhages. Children ≥12 years of age and children with high (≥85th percentile) BMI for age were more likely to experience multiple PTH. Multiple PTH was not associated with medical comorbidities, surgery indications, surgical technique, and perioperative medications. Limitations included a lack of information from patients who went to other emergency departments for hemorrhage management, a possible underestimation of patients with coagulation disorders, and a potential lack of statistical power to evaluate rare conditions or use of certain medications.
Citation: McKeon M, Kirsh E, Kawai K, Roberson D, Watters K. Risk factors for multiple hemorrhages following tonsil surgery in children. Laryngoscope. 2019:129:2765–2770.