Are your tonsillectomy patients at risk for bleeding? Mayo study sheds light
Research can improve how you educate patients and parents
A newly presented study from the Mayo Clinic in Rochester, MN, found outpatients were no more at risk for post-tonsillectomy hemorrhage than inpatients. In fact, age was found to be the only statistically significant risk factor for post-tonsillectomy hemorrhage. The study, which found hemorrhaging occurs most often in postoperative days five through seven, found that ages 11 to 30 were at the highest risk for bleeding. The study also found that 12% of bleeders experienced a second episode of hemorrhaging, typically three to four days after the initial episode.
The study has implications for same-day surgery programs, which need to ensure that patients — and, in the case of pediatric patients, their parents — are thoroughly educated about the risk and treatment for postoperative hemorrhaging. A special emphasis may be necessary for those who fall into the 11 to 30-year-old group. The study, "Evaluation of post- tonsillectomy hemorrhage and risk factors," was presented at the September meeting of the Alexandria, VA-based American Academy of Otolaryngology — Head and Neck Surgery. (For information on how to order a copy of the study, see source box, p. 128.)
The Mayo clinic studied 4,662 tonsillectomy patients over 13 years (1985-1997). Approximately 40% were outpatients, 40% were 23-hour observation patients, and 20% were inpatients. The patients were ages 2 to 41. Of the total cases, 90 (1.93%) experienced bleeding after surgery. This compares with published post-tonsillectomy hemorrhage rates of 0.1-9.3%, says Julie L. Wei, MD, resident in the department of otorhinolaryngology at the Mayo Clinic and one of the study authors. For every patient who bled, the authors compared two tonsillectomy cases with the same gender and age that had occurred within a year of the procedure, with no hemorrhaging. The purpose was to determine if there were any statistically significant risk factors.
Only one patient of the 90 who experienced post-tonsillectomy hemorrhaging had bleeding within 24 hours, Wei points out. "Secondary" hemorrhaging, or bleeding after the first 24 hours, occurred most often five to seven days after surgery. The reason was most likely the eschar, or scab, falling off, Wei says.
What are risk factors for bleeding?
The researchers examined multiple factors to determine if they put patients more at risk for bleeding. They found the following potential risk factors had no statistical significance: whether the procedures was inpatient, outpatient, or 23-hour observation; preoperative diagnosis; surgical method; blood pressure before and after surgery; pain medication; and blood loss.
"Only age was found to be statistically significant," Wei says. While the overall rate of post-tonsillectomy hemorrhaging was 1.9%, ages 21 to 30 had a 3.61% incidence of bleeding, and ages 11 to 20 had 2.48% incidence of bleeding.
That finding is consistent with what many same-day surgery managers see. Celine Belling, RN, BSN, CNOR, director of nursing at Children’s Hospital of Buffalo/Kaleida Health in Buffalo, NY, says, "We see few tonsil bleeds, but when we do, it’s teens, and six to seven days after surgery." Belling points out that her hospital treats few adult patients.
Lack of compliance with discharge instructions, such as instructions to avoid high levels of activity, is a likely culprit, say Wei and same-day surgery managers.
Bette Nelson, RN, day surgery nurse manager at Driscoll Children’s Hospital in Corpus Christi, TX, says, "[Adults] think they’re feeling OK, and they get up and do things they wouldn’t let their children do."
Wei agrees and says the 21 to 30-year-olds, who experienced the highest rates of bleeding in the Mayo study, present particular challenges. "That age is more likely to eat and drink [alcohol], have pizza and burgers." These patients also may experience a rise in blood pressure, she says. Some physicians say that patients in this age range also have had more infections and scarring, so the tonsils are more difficult to remove, Wei adds.
Lack of hydration also may be a factor, Nelson says. "I don’t know if adults are drinking as much as their children do [after tonsillectomies]," she says.
However, Wei cautions, don’t interpret the study finding to mean you shouldn’t perform tonsillectomies on ages 21 to 30. "Keep in mind that 3.61% is still very reasonable" as a post-tonsillectomy hemorrhage rate, Wei says. But advise patients to avoid vigorous exercise, she suggests.
The Mayo study indicates that the history and physical (H&P) is critical to decrease likelihood of post-op hemorrhage. Factors such as recent tonsillitis and peritonsillar abscess may increase the likelihood of post-op hemorrhage, and previously diagnosed coagulopathies mandate pre-op management, the study says.
In addition to the physician H&P, Children’s Hospital has another H&P conducted by a nurse practitioner. This second H&P is needed to comply with a state law that requires an H&P to be performed within 30 days of surgery, because physicians often schedule surgery more than 30 days in advance. The nurse practitioner asks patients about any chronic illnesses, childhood illnesses, aspirin use, recent illnesses, and exposure to chicken pox, among other items, Belling says.
The Mayo study authors advise that routine pre-op coagulation profiles aren’t cost-effective in predicting risk of post-op bleeding. The cost is $150 per patient to perform the four tests, Wei says. The Mayo Clinic doesn’t perform these tests routinely, she says.
"Even if I tested everyone, I don’t think it would tell me who those people are [who are at risk of bleeding], based on the literature written on the subject," Wei maintains.
However, patients should be questioned about whether they have a family history of bleeding problems or easy bruising, she adds.
Belling agrees that the tests probably aren’t cost-effective, although Children’s Hospital continues to perform them. "From my experience, I don’t know if we’ve ever cancelled a case because a patient had a high PT [prothrombine time] or PTT [partial prothrombine time]," she says. "But physicians in this area, upper New York state, are fairy conservative, so they’re still doing the PT/PTT test prior to surgery."
Hydration, hydration, hydration!
Hydration is another factor to prevent post-tonsillectomy hemorrhage that was strongly emphasized in the study and by managers interviewed by Same-Day Surgery.
"Patients are in pain and want to swallow less, and it’s a vicious cycle," Wei says. "Dehydration may make you more susceptible to bleeding."
At Children’s Hospital, tonsillectomy patients who are going home in less than 24 hours are given a bolus of fluids in the recovery room and on the floor. Also, flavored ice on a stick, ice, and water are offered, Belling says.
Driscoll has a similar approach. "The minute a child gets back from surgery, we immediately start with fluids," Nelson says. Parents are asked to put ice chips in children’s mouths if the children aren’t ready to drink, Nelson says.
"We want them to have a [paper] cup of ice chips in the first 45 minutes," she says. "When children do that, the ones that start liquids right away will be feeling better, sitting up, looking better, and asking for more liquids. The other ones are not even swallowing their saliva."
Driscoll educators make it clear that it’s the parents’ responsibility to give the children fluids, although the children are not going to want it. "We tell them that’s normal," Nelson says.
Also, parents are also instructed to have liquids, such as flavored ice on a stick, at home, she says.
Driscoll also gives children a bolus of fluid through an IV before they’re discharged, Nelson says. "Most children have been NPO before surgery, so they go into surgery with a little deficit [of fluids], she says. "These are healthy, normal children, so there’s no problem with extra fluid."
Constantly reinforce the advantages of fluid intake with parents, Nelson advises. "We say, This is great. They’re drinking well. Keep it up when you get home. See how much better he looks?’"
In the post-op call, ask parents how much fluid the child is taking, and encourage parents to continue offering fluids, she says. Such policies pay off, Nelson advises.
"We have approximately 350-400 tonsillectomies a year. We had one come back last year [for bleeding]," she says. "Education is the reason. And we make sure they are drinking very well before they leave here." (See more on discharge instructions for tonsillectomy patients, p. 127.)
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