From the Guidelines
Controlling post-tonsillectomy hemorrhage requires prompt intervention with both immediate measures and definitive treatment, with the most critical step being immediate control of obvious bleeding points, as outlined in the management of massive haemorrhage 1.
Immediate Actions
To control bleeding in post-tonsillectomy hemorrhage, the following immediate actions should be taken:
- Apply direct pressure to the bleeding site using gauze soaked in 1:1000 epinephrine solution or topical tranexamic acid
- Position the patient upright and leaning forward to prevent blood aspiration
- Administer high FO2I and maintain IV access with the largest bore possible, including central access if necessary 1
- Perform baseline blood tests, including full blood count, prothrombin time, activated partial thromboplastin time, and Clauss fibrinogen, and consider near-patient testing such as thromboelastography or thromboelastometry if available 1
Definitive Management
If bleeding persists, definitive management involves:
- Returning to the operating room for surgical control under general anesthesia
- The surgeon identifying the bleeding vessel and achieving hemostasis using electrocautery, suture ligation, or silver nitrate application
- In severe cases, external carotid artery ligation may be necessary
- Intravenous fluids should be administered to maintain hemodynamic stability, and blood transfusion may be required for significant blood loss 1
- Coagulation studies should be performed to rule out underlying bleeding disorders
Post-Intervention Care
Post-intervention, patients need close monitoring for at least 24 hours, with attention to:
- Vital signs
- Hemoglobin levels
- Potential complications such as nausea, vomiting, pain, and dehydration 1 Bleeding can occur due to sloughing of eschar during the healing process, typically 5-10 days post-surgery, when blood vessels become exposed as the protective clot dissolves.
Key Considerations
It is essential to note that complications are more common in children with craniofacial disorders, Down syndrome, cerebral palsy, neuromuscular diseases, major heart disease, or bleeding diatheses, and in children under 3 years of age 1. Current US reported mortality rates for tonsillectomy are 1 per 2360 and 1 per 18,000 in inpatient and ambulatory settings, respectively 1.
From the FDA Drug Label
Tranexamic acid injection is an antifibrinolytic indicated in patients with hemophilia for short-term use (2 to 8 days) to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction
The FDA drug label does not answer the question about controlling bleeding in post-tonsillectomy hemorrhage.
From the Research
Methods for Controlling Bleeding in Post-Tonsillectomy Hemorrhage
- Standard surgical maneuvers, including the use of electrocautery, application of topical hemostatic agents, direct pressure, and suturing of the tonsillar pillars, are traditionally used for the treatment of severe bleeding 2
- Endovascular approaches, such as coil embolization of the tonsillar artery, can be an effective treatment for severe post-tonsillectomy hemorrhage when other techniques are unsuccessful 2
- The use of tranexamic acid (TXA) is being studied as a potential treatment for post-tonsillectomy hemorrhage, with some evidence suggesting its effectiveness in controlling bleeding 3, 4
- Nebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention 4
Predictors of the Need for Surgical Treatment
- Patients aged 6 years or older who experience post-tonsillectomy hemorrhage during the first postoperative week are more likely to require surgery to control bleeding 5
- Adults, bleeding from both tonsils, and receiving blood transfusion are independent predictors of the need for surgical treatment to control post-tonsillectomy hemorrhage 5