TY - JOUR
T1 - Management of paediatric post-tonsillectomy bleeds – does everyone need observation?
AU - O'Neil, Luke M.
AU - Garcia-Matte, Raimundo J.
AU - Sale, Phillip
AU - Vijayasekaran, Shyan
N1 - Funding Information:
In our study, the cohort of patients with no oropharyngeal clot on review (n = 275) were at very low risk of rebleeding with 4 (1.4%) having a further bleed while admitted, and only 2 (0.73%) managed operatively. In contrast, Yuen et al. had a larger rebleed rate in their review of 337 sPTB patients who presented with no evidence of bleeding [6]. They reported 33 (9.7%) patients having further bleeding that required operative intervention, with 83% occurring within the first 24 h [6]. In our cohort of patients with no evidence of bleeding on presentation, the average time to rebleed was 10.6 h, with those requiring surgical intervention rebleeding at an average 9.6 h. There are multiple studies that are congruent with our findings of a low intervention rate in rebleeding cases, including Attner (2009) who identified that patients with no evidence of bleeding at presentation are at low risk of recurrent bleeding, with 8 patients (7%) in their study rebleeding from 114 admissions [5]. In their cohort, only 1 patient (0.9%) who rebled while under observation required a return to theatre, however 7 required bipolar under local anaesthetic [5]. Further supporting our findings is a review of 90 paediatric sPTB presentations by Peterson & Losek, who had 14 patients admitted with an sPTB with a normal oropharyngeal examination, with no patients have further bleeding while under observation [2] Furthermore, Arora et al. (2015) reviewed their post-tonsillectomy bleed admissions and created a policy for consideration of early discharge in patients with a small volume bleed and normal oropharyngeal examination [3]. Their policy change was midway through their review thus the majority of patients were admitted for observation (71.9%), with no patients with a normal oropharyngeal examination rebleeding or requiring operative intervention (n = 13) [3]. In addition, no patient with a normal oropharyngeal examination who was discharged from the emergency department (n = 29) required intervention [3]. Our study, in combination with published literature, suggests there is a low risk of further bleeding in patients who present with no evidence of bleeding and therefore this cohort should be considered for early discharge. All patients within this group should be reviewed by an Otolaryngologist, live locally, have reliable care providers, and be thoroughly counselled on the risk of rebleeding. If these criteria aren't met, the patient should be admitted for a period of observation.
Publisher Copyright:
© 2023 Elsevier B.V.
PY - 2023/8
Y1 - 2023/8
N2 - Aim: The management of patients who present with a post-tonsillectomy bleed (PTB) who are not actively haemorrhaging is contentious. In our institution, those without an active bleed are admitted for a period of observation, due to the theoretical risk of further bleeding. This paper aims to review PTB admissions to ascertain the risk of rebleeding while under observation and to identify whether there is a low-risk group who can be safely discharged without observation. Methods: Review of current literature. Retrospective chart review of all patients who presented to Perth Children's Hospital between February 2018 and February 2022 with a PTB. Exclusion criteria included primary PTB, known blood dyscrasias and patients >16 years of age. Results: A total of 826 presentations of secondary PTB (sPTB) were reviewed, with 752 admitted for a period of observation. Twenty-two (2.9%) patients rebled while under observation, with 17 managed operatively. The average age of patients who rebled was 6.2 years and they presented at an average 7.14 post-operative days. The median time to rebleed was 4.4 h. Four patients with no oropharyngeal clot at presentation subsequently re-bled (0.53%) while under observation, with 2 (0.26%) managed surgically. In patients observed with an oropharyngeal clot at presentation 18 (3.1%) rebled, with 15 (2.6%) managed operatively. Conclusion: Patients presenting with a sPTB have a low risk of rebleeding while under observation. Patients with a normal oropharyngeal examination at presentation have a very low risk of rebleed and should be considered for early discharge if they meet other low risk criteria. Patients who present with an oropharyngeal clot can be safely observed with a low risk of further bleeding. Patients who rebleed while under observation should have a trial of conservative management if clinically appropriate.
AB - Aim: The management of patients who present with a post-tonsillectomy bleed (PTB) who are not actively haemorrhaging is contentious. In our institution, those without an active bleed are admitted for a period of observation, due to the theoretical risk of further bleeding. This paper aims to review PTB admissions to ascertain the risk of rebleeding while under observation and to identify whether there is a low-risk group who can be safely discharged without observation. Methods: Review of current literature. Retrospective chart review of all patients who presented to Perth Children's Hospital between February 2018 and February 2022 with a PTB. Exclusion criteria included primary PTB, known blood dyscrasias and patients >16 years of age. Results: A total of 826 presentations of secondary PTB (sPTB) were reviewed, with 752 admitted for a period of observation. Twenty-two (2.9%) patients rebled while under observation, with 17 managed operatively. The average age of patients who rebled was 6.2 years and they presented at an average 7.14 post-operative days. The median time to rebleed was 4.4 h. Four patients with no oropharyngeal clot at presentation subsequently re-bled (0.53%) while under observation, with 2 (0.26%) managed surgically. In patients observed with an oropharyngeal clot at presentation 18 (3.1%) rebled, with 15 (2.6%) managed operatively. Conclusion: Patients presenting with a sPTB have a low risk of rebleeding while under observation. Patients with a normal oropharyngeal examination at presentation have a very low risk of rebleed and should be considered for early discharge if they meet other low risk criteria. Patients who present with an oropharyngeal clot can be safely observed with a low risk of further bleeding. Patients who rebleed while under observation should have a trial of conservative management if clinically appropriate.
KW - Admission
KW - Haemorrhage
KW - Observation
KW - Tonsillectomy
UR - https://www.scopus.com/pages/publications/85161491627
U2 - 10.1016/j.ijporl.2023.111622
DO - 10.1016/j.ijporl.2023.111622
M3 - Article
C2 - 37321068
AN - SCOPUS:85161491627
SN - 0165-5876
VL - 171
JO - International Journal of Pediatric Otorhinolaryngology
JF - International Journal of Pediatric Otorhinolaryngology
M1 - 111622
ER -