Post‐Tonsillectomy Hemorrhage and the Diagnosis of Occult Pediatric Coagulopathies

Abstract

Objectives/Hypothesis: The primary objective of this investigation was to determine rates of abnormal coagulation panels and diagnoses of coagulopathies in children with post-tonsillectomy hemorrhage (PTH). Secondary objectives identified patient demographics and hemorrhage event characteristics that correlated with a coagulopathy diagnosis.Study Design: Case series with chart review. Methods: Patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 were included. Details of tonsillectomy procedures and hemorrhage events were reviewed along with screening labs for coagulopathy, referrals to hematology and bleeding disorder diagnoses.Results: There were 250 children included. Mean age was 8.8 years (95% CI: 8.2-9.4) and 53.6% were males. PTH events occurred at a median of postoperative day six (mean: 5.9, 95% CI: 5.4-6.3), and 14.8% occurred within 24 hours of surgery. In this series, 23 patients (9.2%) had a second PTH, and three (1.2%) had a third PTH. Single and multiple PTH patients were similar with respect to age, gender, postoperative day, and technique (P > .05). Screening coagulation panels were obtained on presentation in 67.8% of children with one PTH and abnormally elevated in 38.3%. All children with multiple PTHs had labs drawn with 34.8% having elevated levels. No child with a single PTH was diagnosed with a bleeding disorder. Conversely, 87.0% of children with multiple PTHs saw hematology and three (13.0%) were diagnosed with a bleeding disorder (P < .001).Conclusions: Obtaining coagulation panels in pediatric patients presenting with PTH is rarely useful and diagnosing a coagulopathy is uncommon. However, among children with a second PTH, referral to hematology is reasonable as this group has a significantly higher, albeit small, incidence of undiagnosed bleeding disorders.

Estimated Probability Distribution of Bleeding After Pediatric Tonsillectomy

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Pediatric Anesthesia Management for Post-Tonsillectomy Bleed: Current Status and Future Directions

“…In 2020, a case series that included a chart review of 250 children with PTH attempted to define the rate and identify characteristics of post tonsillectomy bleeding that would lead to a diagnosis of occult coagulopathy. 9 The authors found that even in children presenting with multiple episodes of post tonsillectomy bleeding, a diagnosis of coagulopathy was rarely uncovered. In the 250 children presenting with PTH, only three were diagnosed with an occult coagulopathy (13%).…”