post tonsilectomy

1. POST TONSILLECTOMY
BLEEDING
DR RIZWAN ANSARI
FCPS
BILAWAL MEDICAL COLLEGE LUMHS

3. AIRWAY MANAGEMENT FOR SHARED AIRWAY SURGERY
 Surgical pathological conditions and the fact that the airway is shared by the
anaesthetist and surgeon can create challenges in managing the airway
INTRODUCTION

4.  Tumours, abscesses, facial trauma, bleeding,
anatomical variation such as receding mandible,
obstructive sleep apnoea and other inflammatory
conditions affecting the head and neck can all
contribute difficulties

5. You are called to see a 4-year-old boy on the
paediatric ward. He had a tonsillectomy 4
hours ago and has been vomiting blood for the
last hour. His heart rate is 150 and his blood
pressure is 95/60.
CASE SCENERIO

6. What are the problems in managing
this case?

7. PROBLEMS WITH PRIMARY POST-TONSILLECTOMY
HAEMORRHAGE (<24HRS)
 Frightened child and anxious parents
 Hypovolaemia
 Full stomach
 Residual effects of the anaesthetic 4 hours earlier
 Difficult intubation – bleeding and possible upper
airway oedema from the previous intubation and
surgery

8.  Review of the previous anaesthetic chart and history and
examination are, of course, mandatory.
 The consultant anaesthetist should be informed.
 It is vital to ensure he is adequately resuscitated before
embarking on another anaesthetic.
 Intravenous access (or interosseous if needed) should be
established and resuscitation commenced with
crystalloid/colloid 20 ml/kg

9. How would you estimate blood loss?

10.  The most helpful indicators of hypovolaemia are:
 Heart rate
 Pulse volume
 Capillary refill time (pressure for 5 seconds then release, normal
refill
 Skin colour (mottling/pallor/peripheral cyanosis)
 Blood pressure (80 + (2 × age in years), hypotension is a late
 sign Conscious level

11.  The degree of blood loss is often under-estimated.
 Looking at the amount of blood vomited will be inaccurate because much of it is
likely to have been swallowed.
 Postural hypotension suggests significant hypovolaemia but measuring this
would not be practical in a frightened child.
 Core:peripheral temperature difference >2 ◦C is a sign of poor perfusion to skin.
 Respiratory rate may be high as a compensatory response to hypovolaemic
metabolic acidosis.
 He should have blood cross-matched and available in theatre. FBC and clotting
should be checked pre-operatively.

12. What anaesthetic technique would you employ?

13. There are two schools of thought as to the method of
induction
1.RAPID SEQUENCE INDUCTION WITH CRICOID
PRESSURE
2.GAS INDUCTION IN THE HEAD-DOWN, LEFT LATERAL
POSITION

14.  A rapid sequence induction with cricoid pressure in the supine
position is likely to be the most familiar technique. Although it is
recognised that cricoid pressure does not protect the airway from
bleeding in the pharynx.
 A gas induction in the head-down, left lateral position may be
fraught with potential problems.
 There should be two suction devices in case one becomes blocked
with clot and a variety of tube sizes and laryngoscope blades.
 The ENT surgeon needs to be scrubbed and prepared to perform a
tracheostomy should the need arise.

15. Following intubation, a nasogastric tube may be inserted to empty the
stomach.
This is then removed prior to extubation.
Once haemostasis is achieved, the child is extubated awake and in the
head-down, left-lateral position

16. THANK YOU