Describe the anesthetic management of a patient presenting with post-tonsillectomy hemorrhage

Describe the anesthetic management of a patient presenting with post-tonsillectomy hemorrhage.

The majority of post-adenotonsillectomy hemorrhage occurs with a biphasic pattern. The most common bleeding falls within the first 8 hours after surgery. The next significant risk period is 7–10 days postoperatively when the eschar falls away from the surgical site. Post-adenotonsillectomy hemorrhage usually results from significant emesis, retch-ing, or straining secondary to swallowed blood or pain. Adequate treatment of emesis and pain will reduce the risk of such hemorrhage. Coagulation studies may be warranted at this time.

Preparation for anesthetic induction begins with intravascular volume replacement. Although a blood trans-fusion may be required, crystalloid administration gener-ally suffices. Nevertheless, compatible blood should be available. Essential monitoring consists of pulse oximetry, precordial stethoscope, noninvasive blood pressure cuff, electrocardiogram, and capnography. Formerly, uncooper-ative children received inhalation induction in the lateral decubitus position. The current recommendation for pre-operative volume replacement virtually eliminates the need for an inhalation induction, which may increase the risk of hypotension, laryngospasm, and aspiration pneumonitis. Etomidate or ketamine should be selected for those who remain hypovolemic.

Rapid sequence induction with cricoid pressure and a cuffed endotracheal tube help reduce the risk of aspiration. Evacuation of stomach contents reduces postoperative nau-sea and vomiting. Narcotic-based maintenance anesthesia may facilitate awake extubation, while limiting coughing and retching on the endotracheal tube. “Stormy” emergences predispose patients to re-bleeding from the surgical site.