Anesthesiology APPLIED Exam › Pediatric and neonatal

Tonsillectomy and the bleeding tonsil

T1Pediatric and neonatal·974 words · ~5 min read·v0.1DRAFT

Why examiners ask this

Tonsillectomy packs three examinable problems into one short case: obstructive sleep apnea that changes opioid dosing and disposition, a shared airway with the surgeon, and the post-tonsillectomy bleed, which is the pediatric full-stomach, hypovolemic, difficult-airway induction in its purest form. The examiner is testing judgment about the sleep-apnea child, organization during a crisis induction, and adaptability when the first laryngoscopy shows nothing but blood.

The 60-second answer

For the elective case I first classify the child: a child with severe obstructive sleep apnea, under 3 years, or with a comorbidity such as Down syndrome or obesity is admitted overnight, and I cut opioid doses by half because sleep apnea upregulates opioid sensitivity. I induce with sevoflurane, place an oral RAE tube, give dexamethasone 0.5 mg/kg to a maximum of 8–10 mg and ondansetron, use acetaminophen and ibuprofen as the base of analgesia, and extubate awake after suctioning the pharynx under direct vision. For the bleeding tonsil I treat it as hypovolemia first: two intravenous lines, 20 mL/kg boluses, a hematocrit and a type and cross, then a rapid sequence induction with the child head-down, two working suctions, a styletted tube one size smaller, and a surgeon scrubbed. The stomach is full of swallowed blood, so I empty it with an orogastric tube before extubation and extubate awake.

Decision points and the "why"

Admission versus discharge — the sleep-apnea child obstructs and hypoventilates on the first postoperative night; age under 3, severe apnea on polysomnography, failure to thrive, cardiac disease or craniofacial abnormality means admission with continuous oximetry. A healthy child over 3 with mild symptoms goes home after 4–6 hours of observation.
Opioid dosing — recurrent hypoxemia sensitizes the opioid receptors; I give morphine 0.05 mg/kg or fentanyl 0.5 mcg/kg and titrate to respiratory rate. Codeine is contraindicated because ultra-rapid metabolizers die from it.
Steroids and NSAIDs — dexamethasone reduces vomiting and the time to oral intake; ibuprofen does not increase bleeding in the meta-analyses and reduces opioid need, so I use it unless the surgeon objects.
Bleeding tonsil: resuscitate before induction — the child has been swallowing blood for hours and the vital signs lie; tachycardia and a normal pressure mean a 15–20% deficit. I induce only after a bolus and with blood available, because propofol into an empty tank produces arrest.
Induction technique for the bleed — rapid sequence with propofol at a reduced dose or ketamine 1–2 mg/kg if the pressure is soft, succinylcholine 2 mg/kg, cricoid pressure, head-down to drain blood away from the larynx, and a tube with a stylet because the view is wet. An inhalational induction in the lateral position is the alternative when there is no intravenous access, but it delays the airway and I prefer to get a line.
Extubation after the bleed — stomach emptied, fully awake, lateral, with the surgeon's confirmation of hemostasis; I keep the child in recovery long enough to see that the bleeding has not restarted.

The complication they will inject

I induce the bleeding child, and laryngoscopy shows only pooled blood. I keep cricoid pressure on, use the second large-bore Yankauer, and look for bubbles in the blood as the marker of the glottis while an assistant suctions. If I cannot see, I put the styletted tube where the bubbles are and confirm with capnography. If that fails, I ventilate with a mask and a jaw thrust, head-down, accepting some gastric insufflation, and I ask for a video laryngoscope and a laryngeal mask as the next steps, with a surgeon ready for a surgical airway. The second inject is hypotension after induction with a saturation that holds: the cause is hypovolemia, so I give a further 20 mL/kg and start blood if the hematocrit is below 25% or the bleeding continues, and I ask the surgeon to get control before I chase the pressure with vasopressors.

Pitfalls that cost points

Describing the elective case without classifying the sleep-apnea risk and the disposition.
Treating the bleeding tonsil as an airway problem alone and inducing a hypovolemic child without resuscitation.
Full-dose opioids in a child with severe obstructive sleep apnea.
Prescribing codeine.
Extubating the post-bleed child deep because the pharynx is sore; the stomach is full of blood.

Rapid-why

Q: When do post-tonsillectomy bleeds occur? A: Primary within 24 hours, from surgical hemostasis; secondary at 5–10 days, when the eschar sloughs, which is why the child arrives from home.

Q: Why does sleep apnea increase opioid sensitivity? A: Intermittent hypoxemia upregulates mu-opioid receptor density and sensitivity, so the same dose produces more respiratory depression.

Q: Why head-down for the bleed induction? A: Blood drains out of the mouth rather than into the larynx and trachea, and it is easier to suction a pool than a trickle.

Q: Why an orogastric tube before extubation? A: Swallowed blood is a potent emetic and an aspiration risk; emptying the stomach lowers both.

Numbers to know

Item	Value
Admission triggers	Age <3 y, severe OSA, obesity, Down syndrome, cardiac or craniofacial disease
Dexamethasone	0.5 mg/kg, maximum 8–10 mg
Opioid dose in severe OSA	Half the usual: morphine 0.05 mg/kg or fentanyl 0.5 mcg/kg
Fluid bolus for the bleed	20 mL/kg isotonic crystalloid, repeated; blood if Hct <25%
Secondary bleed timing	Days 5–10
Induction for the bleed	Ketamine 1–2 mg/kg or reduced propofol; succinylcholine 2 mg/kg

Sources

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