Post Tonsillectomy Bleed

Last updated on 06 Nov 2025

Take home messages

Post tonsillectomy bleeding is the most common serious complication of an otherwise common procedure
The airway is always high risk
Have the question of an undiagnosed bleeding disorder in the back of your mind

Picture this

You are the anaesthetic registrar assigned to an elective paediatric ENT list with your favourite consultant on a beautiful Thursday morning in November.

The weather is gorgeous
You found a great parking space
The coffee has just started tickling your synapses

What more could you ask for?

Two beautiful gas inductions and slick vasoplegic cannulations later and you're feeling pretty awesome if you do say so yourself. Your consultant has been grilling you on nuanced paediatric physiological niceties, which of course you've smashed out the park, and now you're settling down for coffee number two in the best armchair in the coffee room.

And then the alarm bell goes.

Coffee down, off we go.

Into recovery

You swoop into recovery to find an exceedingly agitated five year old girl with blood around her mouth and pillow swatting away the well-intentioned and only marginally less agitated recovery nurse.

The child's mother, somewhere between the two on the agitation scale, is shouting at anyone who will listen to 'just do something'.

What are the clinical signs of hypovolaemia in a five year old with post-tonsillectomy bleeding?

Early signs:

Tachycardia
Tachypnoea
Prolonged capillary refill
Reduced urine output

Late signs:

Altered mental status
Mottling and peripheral cyanosis
Hypotension

A core vs peripheral temperature difference greater than 2°C is suggestive of significant hypovolaemia.

What next?

You approach the scenario in the traditional manner to which you have become faithfully accustomed - airway, breathing, circulation.

Airway

The child is currently screeching the room to pieces, demonstrating that her airway is painfully patent for the moment
It is however soiled with blood
It is also swollen from a combination of surgery and previous anaesthetic manipulation

Breathing

The saturation probe is languishing on the floor, however the child appears pink
The intercostal recession is more likely to be screaming-related than respiratory failure
The respiratory rate is approximately 20 per minute and the tidal volumes are sufficient to make your eardrums throb
She's not coughing, wheezy or crackly

Circulation

Her heart rate is sat at 145 beats per minute
This is likely multifactorial, however does suggest a degree of hypovolaemia
Her capillary refill time is approximately 5 seconds
Her blood pressure is 83/45 mmHg

Neurological status

She's thoroughly pissed off, and appropriately so

Exposure

There's a little blood around the mouth, and a patch or two on the pillow, but the recovery nurse tells you she hasn't seen much blood anywhere else
The child still has a heavily bandaged cannula in the hand, which you are sensibly holding onto rather firmly
There aren't any other injuries or rashes that you can identify

What are your concerns?

This is a post-tonsillectomy bleed, and this child needs to return to theatre, for a second, emergency general anaesthetic.

Her airway is likely to be more challenging than before, and she requires intubation rather than a flexible LMA as you might have used for the previous procedure
She has a stomach full of blood (that's why the nurse didn't see it) and so carries a very high risk of aspiration
She may well have already aspirated some blood, but clinically doesn't appear to have significant respiratory embarrassment
She's substantially hypovolaemic, and likely compensating heavily with endogenous catecholamines, the effect of which will be lost after induction, bringing the risk of profound cardiovascular instability
She (and Mum) are agitated and distressed, which will make logistics and pre-oxygenation somewhat more challenging
She may also be continuing to bleed

It might be that she suffered a small, self-limiting bleed, however these can be deceptive and frequently herald a much larger exsanguination to come.

💡

Post-tonsillectomy haemorrhage occurs in 4-8% of patients and represents the most common serious complication for a common operation

CBA

We're going to flip the algorithm around a little, because in order our priorities are as follows:

She needs a good top up of fluid before any anaesthesia - 10ml/kg balanced crystalloid
She then needs the best preoxygenation you can manage
She then needs to be asleep with a tube as fast as possible

Which brings us nicely to the classic Final SOE short case exam question:

How would you anaesthetise this child for return to theatre?

After calling for skilled assistance, establishing intravenous access, administering a fluid bolus and preparing monitoring and difficult airway equipment, and of course explaining what the hell is going on to the mother and child, you essentially have two options:

Gas induction in the lateral position with head down
Rapid sequence induction with head up and cricoid

It is clearly going to depend on the child, the situation, and the anaesthetist how you choose to proceed.

Benefits of gas induction:

Familiar technique
Blood drains from airway and prevents contamination
Allows for thorough preoxygenation

Downsides of gas induction:

Child may be very agitated and difficult to gas
Risk of cardiovascular instability in hypovolaemic child
Risk of laryngospasm
Unfamiliar position to intubate in

Benefits of RSI:

Reduced aspiration risk
Familiar technique
Rapid control of airway

Downsides of RSI:

Agitated child may not permit proper preoxygenation, so may need to bag during apnoeic period
Risk of stomach insufflation and vomiting

In an agitated child with IV access, you could consider a delayed sequence induction with ketamine to facilitate preoxygenation and positioning, but this will depend on your preference for the technique.

On the table

Your winning streak continues, and you've successfully induced and intubated the child without significant cardiorespiratory embarrassment (we love that phrase).

You are ventilating her adequately, her lungs are nice and compliant and she's oxygenating well on an FiO2 of 30%.

What now?

Continue with C

Look at the child's heart rate, swing on the sats trace, capillary refill and mucous membranes, and consider a venous blood gas to determine if they need further fluid resuscitation or whether blood products are required.

Fluid is 10 ml/kg
Packed RBC is 10 ml/kg
FFP is 10ml/kg

So it's not an overly complex algorithm to follow.

💡

Tranexamic acid is rarely a bad shout, and remember to keep them warm.

Keep talking to the surgeons about what's going on, because 'ah yes just found the little bleeder' is very different to 'I can't seem to find where it's oozing from'.

It is rare to find yourself in a major haemorrhage situation after a tonsillectomy but anything can happen in our wonderful world of anaesthesia so it might be worth just double checking the relevant doses, and always be considering whether this child has an undiagnosed bleeding disorder if they're struggling to make it stop.

Extubation

The bleeding has stopped, the sevoflurane is switched off and we're approaching the runway to land.

How to proceed?

Slip in an NG tube and aspirate as much as possible
This will also give you an idea of cumulative blood loss
Thoroughly suction the upper airway under direct vision so as not to knock the new clot off the tonsil bed
Extubate wide awake in the head down lateral position

Then leave the child well alone, and bandage the cannula up once more.

This child now needs to stay in for 24 hours of observation to ensure no further bleeding occurs.

How would you manage this child's postoperative pain?

Two tonsillectomies are invariably more sore than one, so good multimodal analgesia is required.

Regular paracetamol
Ibuprofen or equivalent (NSAID + paracetamol is synergistic)
Consider an α₂-agonist
Opioids if required, but ideally avoided if possible
Dexamethasone at induction of 0.25 - 0.3 mg/kg will also improve post op pain
Intraoperative ketamine (which you may have used for induction) is also good at avoiding opioid use

If the child has sleep disordered breathing or OSA then halve the opioid dose.

Dexmedetomidine 1 μg kg⁻¹ is similar to 0.1 mg/kg morphine in terms of analgesic effect.

Here's a useful Reddit thread

References and Further Reading

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