Post-tonsillectomy bleed with von Willebrand disease8-year-old boy, 26 kg, back 5 hours after tonsillectomy with fresh bleeding
Bleeding tonsil: hypovolaemic child, full stomach of blood, bleeding disorder
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Know this first
- Most tonsil bleeds come within 6 hours; swallowed blood hides the true loss.
- Children keep their blood pressure until shock is advanced; hypotension is late.
- Desmopressin 0.3 mcg/kg IV, 30 minutes before surgery, helps type 1, not type 3.
- Full stomach of blood: rapid sequence with suction, blades and tubes in duplicate.
The patient
The examiner asks
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Consider
What concerns you?
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- An 8-year-old with von Willebrand disease, bleeding after tonsillectomy, for emergency return to theatre. Patient
- As a child he holds his BP until late; his HR of 138 and slow refill already show shock.
- He has swallowed an unknown volume; his Hb fall understates the loss. Disease
- Untreated type 1 von Willebrand disease adds to the surgical bleed.
- Stomach full of blood, blood in the airway, and a raw, swollen pharynx. Airway
Prepare
How will you prepare him?
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- Resuscitate before induction: IV access, crystalloid 10–20 mL/kg, reassessing his perfusion. Stem trigger
- Blood crossmatched; transfuse if his perfusion or Hb keeps falling.
- Haematology now: desmopressin 0.3 mcg/kg IV, ideally 30 minutes before surgery. Disease
- After desmopressin, sodium is checked and he gets isotonic fluids only.
- Tranexamic acid 15–20 mg/kg IV, maximum 1 g, then 2 mg/kg/h.
- Two suctions, laryngoscopes and tubes ready in duplicate, including a smaller tube. Airway
Plan
How will you anaesthetise him?
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- Rapid sequence induction with suction running, because his stomach holds blood. Airway
- Induction suited to his hypovolaemia: ketamine 1–2 mg/kg IV holds his pressure.
- Fast-onset relaxant: rocuronium 1.2 mg/kg; suxamethonium 2 mg/kg is the alternative.
- Styletted cuffed tube; the smaller size open beside it.
- Before waking, his stomach is emptied through an orogastric tube. After surgery
- Extubated awake on his side; HDU afterwards with haematology following his clotting.
Crisis
At laryngoscopy his pharynx fills with blood and you cannot see the cords; SpO2 92%. What do you do?
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- Bloody airway: head-down tilt to keep blood out of his lungs. (Crisis)
- Large-bore suction leads the blade; my assistant runs the second sucker.
- Oxygen between attempts; I limit attempts and call for senior help.
- Can't intubate: an SGA can rescue oxygenation while the surgeon packs the fossa.
- ENT ready for a surgical airway if we can't oxygenate.
Crisis
After haemostasis and an awake extubation, he coughs fresh blood 10 minutes later; HR 150, BP 84/50. What do you do?
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- Re-bleeding with shock: call ENT back; him on his side, head down, 100% oxygen. Crisis
- Second large-bore line; crystalloid 10–20 mL/kg, then warmed blood.
- Repeat rapid sequence induction: he's a full stomach again.
- Tranexamic acid infusion continues; haematology decides on factor replacement.
- Back to theatre for surgical control, then HDU. After surgery
Fatal mistakes
- Induction before IV access and volume resuscitation.
- One sucker and one laryngoscope for a bloody airway.
- Ignoring his von Willebrand disease in the haemostasis plan.
- Deep extubation with a stomach full of blood.
Checked against: Barash 9e · Miller 10e · 2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 8. Pediatric advanced life support (2026)
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