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International Practice Variation in Post-Tonsillectomy Hemorrhage: A Survey Study of Pediatric Otolaryngologists
Gina M Spencer1, Claire A Wilson2, Jacob Davidson2
1Queen's University School of Medicine Kingston Ontario Canada.
Insights
Post-tonsillectomy bleeding (PTB) management lacks standardized practices globally. This study highlights variations in defining, admitting, and treating pediatric tonsil bleeds, informing future clinical guidelines.
Area of Science:
- Otolaryngology
- Pediatric Surgery
- Clinical Practice Guidelines
Background:
- Post-tonsillectomy bleeding (PTB) is a significant complication in pediatric surgery.
- Current management strategies for PTB are not standardized internationally.
- Understanding global variations in PTB management is crucial for developing best practices.
Purpose of the Study:
- To consolidate and analyze international similarities and differences in the management of pediatric post-tonsillectomy bleeding.
- To identify variations in clinical decision-making regarding PTB definition, operative intervention, and patient observation.
Main Methods:
- A cross-sectional online survey was distributed to pediatric otolaryngologists in 22 countries.
- The survey included 55 items addressing PTB definition, operative criteria, surgical techniques, and post-operative observation protocols.
- A total of 112 responses were collected, achieving a 38.2% response rate.
Main Results:
- Definitions of tonsil bleeds varied, with 49.2% defining it as any bleeding presenting to the hospital.
- Operative management was employed by 58.3% for active bleeding, with criteria including severity and hemodynamic instability.
- Bipolar cautery was the preferred OR treatment (60.6%), and 57.3% admitted all PTB patients for 23-hour observation.
Conclusions:
- There is a lack of standardized best practices for managing pediatric post-tonsillectomy bleeding worldwide.
- Significant variations exist in defining tonsil bleeds, readmission criteria, and in-hospital versus out-of-hospital management.
- Further research and international collaboration are needed to develop evidence-based clinical practice guidelines for PTB.
Background:
A significant complication of pediatric tonsillectomy is post-tonsillectomy bleeding (PTB). Management within and outside of the operating room (OR) is not standardized. We consolidated international similarities and differences in PTB management.
Methods:
This cross-sectional survey study was conducted from April 4 to May 16, 2024. It involved a 55-item questionnaire distributed online to a sample of pediatric otolaryngologists from 22 countries, and is a part of larger study on tonsillectomy. The study achieved a 38.2% response rate (112 of 293). Eligibility included proficiency in English and currently practicing pediatric otolaryngology.
Results:
A tonsil bleed was defined by 49.2% as any bleeding presenting to the hospital. In all, 58.3% signified taking patients for operative management in the presence of active bleeding. Operative criteria included persistent bleeding on presentation, repeated bleeding while admitted, severity, signs/symptoms of anemia or hemodynamic instability, or age less than 3 and non-cooperative. When treating PTB within the OR, bipolar cautery is used by 60.6%. In all, 57.3% admit all patients experiencing a PTB for 23-h observation versus 21.2% who admit a subset of patients for 23-h observation. In all, 47.7% indicated that they have a formal monitoring program for bleeding rates in their institution/practice. Readmission rates are monitored by 60.7% of respondents.
Conclusion:
There are no standardized best practices for PTB. Our study confirmed moderate numbers of formal monitoring programs, and varying clinical decision rules when defining a tonsil bleed, readmitting a PTB, and management within or outside of the OR. Understanding global variation may facilitate development of future clinical practice guidelines.
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