Anesthesiology APPLIED Exam › Pediatric and neonatal

Tonsillectomy and the bleeding tonsil

Pediatric and neonatal·~5 min read· Physician-reviewed✓ Sourced · 4

Stem

A 6-year-old girl, 21 kg, had a tonsillectomy for obstructive sleep apnea seven days ago. She returns to the emergency department after vomiting dark blood twice at home and is now spitting bright red blood. She is pale and anxious, heart rate 142, blood pressure 96/58, capillary refill 3 seconds. She has no intravenous access, and the surgeon wants her in the operating room now.

Question

How will you prepare and anesthetize this child?

Ideal answer

HeadlineHypovolemic, full stomach, bloody airway: I resuscitate before I induce, because her tachycardia with a normal pressure is compensated volume loss.

Access and 20 mL/kg isotonic fluid. Ideally two lines, intraosseous if a line is slow; the bolus before induction if time allows.¹
Hemoglobin and crossmatch, no waiting. I read the hemoglobin against her volume status and do not delay surgery for results.¹
Two large-bore suctions, downsized styletted tubes, surgeon scrubbed, because blood will obscure the view and the swollen airway may need a smaller tube or surgery.
Head-down or left-lateral, rapid sequence with cricoid pressure: reduced-dose propofol, or ketamine or etomidate if profoundly hypovolemic, with succinylcholine or rocuronium.¹
After hemostasis, large orogastric tube, then extubate fully awake only with intact reflexes.¹

Watch for: hypotension after induction, and bleeding restarting in recovery.

Breaking down the answer

Why resuscitation leads — she has been swallowing blood for hours and the vital signs lie; induction agents in an empty circulation produce arrest. Judgment ahead of airway bravado.
Timing tells the cause — primary bleeds within 24 hours from surgical hemostasis; secondary at about 5–10 days when the eschar separates, which is why she arrives from home.¹ The guideline defines primary as within 24 hours, secondary as later.²
Doses and the alternative — succinylcholine 1–2 mg/kg IV depending on age.¹^,3 With no intravenous access, inhalational induction in the lateral position is the alternative, but it delays the airway, so I prefer a line.
The elective case sets up the bleed — overnight monitoring under 3 years or severe OSA (AHI of 10 or more, or SpO2 nadir below 80%).² Also severe obesity, cor pulmonale or pulmonary hypertension, syndromic children with significant comorbidities,⁴ Down syndrome, craniofacial abnormality, failure to thrive.
Elective analgesia — a single intraoperative dose of dexamethasone, ibuprofen and acetaminophen for pain, and never codeine.²
Opioids in the sleep-apnea child — nocturnal SpO2 nadirs below 85% mean about half the opioid dose; I start fentanyl at 0.5 mcg/kg in moderate or severe OSA.⁴
Extubation after the bleed — lateral, with the surgeon's confirmation of hemostasis; she stays in recovery long enough to see the bleeding has not restarted.

Follow-up question

You induce, and laryngoscopy shows only pooled blood with no landmarks. Her saturation is 94% and falling. What do you do?

Follow-up answer

HeadlineA soiled airway; I say it out loud so the room is ready.

Cricoid pressure stays unless it worsens the view; the second large-bore suction goes in, and I look for bubbles in the blood marking the glottis. Bubbles seen: the styletted downsized tube there, confirmed by capnography. Failing that: mask and jaw thrust, head-down, accepting some gastric insufflation, while I ask for a video laryngoscope and a laryngeal mask, the surgeon ready for a surgical airway. Tube in, hypotensive with a stable saturation: hypovolemia, so a further 20 mL/kg, blood guided by hemoglobin and ongoing loss, and surgical control before vasopressors.¹

Pitfalls that cost points

Describing the elective case without classifying the sleep-apnea risk and the disposition.
Extubating the post-bleed child deep because the pharynx is sore; the stomach is full of blood.

Rapid-fire

Q: When do post-tonsillectomy bleeds occur? A: Primary within 24 hours, from surgical hemostasis; secondary at about 5–10 days, when the eschar separates.¹

Q: Why does sleep apnea increase opioid sensitivity? A: Recurrent nocturnal hypoxemia increases sensitivity, so a child with a nadir below 85% needs about half the dose.⁴

Q: Why is codeine contraindicated? A: Ultra-rapid metabolizers make excess morphine; the guideline says codeine must not be prescribed after tonsillectomy, citing the FDA boxed warning.²

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

Q: Why an orogastric tube before extubation? A: Swallowed blood is an emetic and an aspiration risk; emptying the stomach lowers both.¹

Numbers to know

Item	Value
Inpatient monitoring	Age <3 y or severe OSA (AHI ≥10 or nadir <80%)²
Dexamethasone	0.5 mg/kg, maximum 10 mg¹
Fentanyl in moderate or severe OSA	Start at 0.5 mcg/kg⁴
Ondansetron	0.1–0.15 mg/kg⁴
Fluid bolus for the bleed	20 mL/kg isotonic before induction¹
Secondary bleed timing	About days 5–10¹

Sources

1.Post-Tonsillectomy Bleed (SPA Case Guide) · Society for Pediatric Anesthesia, 2022 · www2.pedsanesthesia.org
2.Clinical Practice Guideline: Tonsillectomy in Children (Update) · AAO-HNS Foundation, 2019 · journals.sagepub.com
3.Anectine (succinylcholine) dosage, from FDA labeling · Drugs.com · drugs.com
4.Tonsillectomy and Adenoidectomy (SPA Case Guide) · Society for Pediatric Anesthesia, 2023 · www2.pedsanesthesia.org

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.