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Digiandomenico S, Conley SF, Johnson VP, Christopherson PA, Haberichter SL, Zhang J, Simpson P, Abshire TC, Montgomery RR, Flood VH. Screening for von Willebrand disease does not impact posttonsillectomy bleeding in a low-risk population. Pediatr Blood Cancer 2021; 68:e29371. [PMID: 34606172 PMCID: PMC8919995 DOI: 10.1002/pbc.29371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/23/2021] [Accepted: 09/05/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Bleeding is an important complication in children following tonsillectomy. Screening with coagulation tests prior to procedure is common to assess bleeding risk in the perioperative period, although ASH/ASPHO Choosing Wisely guidelines recommend against routine PT/PTT testing. Our aim was to compare von Willebrand factor antigen (VWF:Ag) and activity levels among patients with postoperative bleeding following tonsillectomy to evaluate for potential risk for bleeding. PROCEDURE Eligible subjects were aged 0-18 without significant personal or family history of major bleeding. Postoperative bleeding diaries were collected and symptoms measured using a postoperative bleeding score. Plasma VWF levels were drawn at time of anesthesia administration. RESULTS Postoperative bleeding occurred in 248 cases out of 1399 total subjects. Median VWF:Ag was 86 in patients with postoperative bleeding scores of 1-2, 86 for scores 3-4, 84 for scores 5-6, and 83 for scores >6, with no significant difference among groups (p = .98). Additionally, no difference was observed for subjects with multiple days of postoperative bleeding as compared to those with only 1 day of postoperative bleeding. Finally, no difference in VWF:Ag was observed for subjects whose first reported bleed occurred early in the postoperative course compared to those whose first reported bleed occurred later. VWF:Ag does not correlate with severity of bleeding, time of onset of first bleeding event, or recurrence of bleeding in healthy children with no personal or family history of bleeding who have postoperative bleeding following tonsillectomy. CONCLUSIONS This data does not support routine von Willebrand disease screening prior to tonsillectomy.
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Affiliation(s)
- Stefanie Digiandomenico
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Stephen F. Conley
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Victoria P. Johnson
- Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226
| | | | - Sandra L. Haberichter
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226,Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
| | - Jian Zhang
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Pippa Simpson
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226
| | - Thomas C. Abshire
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226,Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
| | - Robert R. Montgomery
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226,Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
| | - Veronica H. Flood
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226,Versiti Blood Research Institute, 8727 Watertown Plank Rd, Milwaukee, WI 53226,Children’s Research Institute, Children’s Hospital of Wisconsin, Milwaukee, WI 53226
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2
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Konanur A, McCoy JL, Shaffer A, Kitsko D, Maguire R, Padia R. Detecting coagulopathy in pediatric patients with post-tonsillectomy hemorrhage. Int J Pediatr Otorhinolaryngol 2021; 147:110807. [PMID: 34192615 DOI: 10.1016/j.ijporl.2021.110807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/07/2021] [Accepted: 06/21/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Post-tonsillectomy hemorrhage (PTH) is a serious complication after a tonsillectomy. Utility of lab work at presentation for PTH was low. This study aims to determine the frequency and type of labs drawn at emergency department (ED) presentation and assess the incidence of uncovering a previously unidentified coagulopathy. METHODS A retrospective chart review was performed on pediatric patients who were seen in the ED after tonsillectomy at a tertiary care children's hospital from 2017 to 2019. Exclusion criteria were the following: no tonsillar bleed, history of known coagulopathy, treated by outside provider, ≥18 years old. Lab work included complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), and von Willebrand factor (VWF). RESULTS 364/723 (50.3%) patients met inclusion criteria. 179/364 (49.2%) patients were male and 309/364 (84.9%) patients were Caucasian. Average age at surgery was 8.12 years (SD = 4.0) and average post-operative day at presentation was 6 days (SD = 2.1). Operative control of bleed was performed in 68/364 (18.7%) patients. 334/364 (91.8%) patients had labs drawn in the ED. 64/334 (19.1%) patients were anemic (hemoglobin (Hgb) < 11), 46/334 (13.8%) patients had thrombocytosis (platelets>450,000), 10/334 (3.0%) had elevated PTT and 8/334 (2.4%) had elevated PT. Hematology was consulted in 14/364 (3.8%) patients of whom 6/14 were diagnosed with von Willebrand disease and 1/14 with factor VII deficiency. Aminocaproic acid was used in 8/364 (2.2%) patients due to elevated PTT in 3/8 and multiple episodes of bleeding in 5/8.3/364 (0.8%) patients needed a blood transfusion. No difference was found in incidence of abnormal lab work in patients who did and did not need operative control of bleed (p = .125). Of the 334 patients who had ED labs drawn, 7 (2.1%) had an uncovered coagulopathy. CONCLUSION Uncovering incidental coagulopathies is rare in patients who present with PTH. Though anemia was the most common abnormality noted, only a small percentage required transfusion, with all having abnormal vital signs. Thrombocytosis was the next common abnormality, and this can be seen in an inflammatory state. Developing algorithms is necessary to better guide appropriate lab work in patients who present with PTH and to provide optimal value of care to patients.
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Affiliation(s)
- Anisha Konanur
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jennifer L McCoy
- Division of Pediatric Otolaryngology, Department of Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Amber Shaffer
- Division of Pediatric Otolaryngology, Department of Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Dennis Kitsko
- Division of Pediatric Otolaryngology, Department of Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Raymond Maguire
- Division of Pediatric Otolaryngology, Department of Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Reema Padia
- Division of Pediatric Otolaryngology, Department of Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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Pai K, Desai H, Stein D, Cole S. Postoperative tonsil/adenoidectomy bleeding management in patients with diagnosed bleeding disorders. Laryngoscope Investig Otolaryngol 2021; 6:872-877. [PMID: 34401515 PMCID: PMC8356851 DOI: 10.1002/lio2.589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 04/05/2021] [Accepted: 05/11/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Tonsil/adenoidectomy (T/A) is a commonly performed procedure with an average post-tonsillectomy bleed (PTB) rate between 3 and 5%. Patients with bleeding disorders (BDs) are believed to have an increased risk of PTB. We hypothesize that our medical management of BD patients using a combination of DDAVP/antifibrinolytic agents has a similar PTB rate to control patients. This study suggests a standardized protocol for patients with BDs to avoid PTB. METHODS A retrospective cohort study was completed for patients with BD who underwent tonsillectomy or T/A at Promedica Toledo or Flower Hospital between 2013 and 2020. Exclusion criteria included incomplete records, diagnosis of BD after surgery, and inability to find age and sex matched control. We defined the control group as patients who underwent T/A without BD. The following variables were collected: age, sex, medical history, BD severity, medications, type of surgery, indication for surgery, estimated blood loss (EBL), pre/postoperative medications, PTB status, and post-PTB intervention. RESULTS A total of 164 patient charts were reviewed. There were 82 patients in both cohorts. The BDs represented were platelet function disorder (80.5%), von Willebrand disease (14.6%), and others such as Factor VII and IX deficiency (4.9%). Of the BD patients included, 13.4% had severe disease. There was no significant difference between the age, sex, EBL, and PTB rates. Of the 8 BD patients with PTB, 62% bled 9-10 days postoperatively and none had severe disease. CONCLUSION Our protocol to prevent PTB in patients with BDs produced similar bleed rates to control patients in this study. Further studies are required to assess postoperative length of antifibrinolytic treatment in BD patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kavya Pai
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | - Harsh Desai
- University of Toledo College of Medicine and Life SciencesToledoOhioUSA
| | - Dagmar Stein
- Pediatric Hematology/Oncology, Promedica Russell J. Ebeid Children's HospitalToledoOhioUSA
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4
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Forrest BP, de Klerk R, Baghaie H, Perry CF. Diagnosis of previously unidentified haemophilia A in a patient following routine endoscopic sinus surgery. OTOLARYNGOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.xocr.2021.100278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Ruiz R, Dedhia K. Adenotonsillectomy in high risk patients: Hematologic abnormalities and COVID-19 considerations. World J Otorhinolaryngol Head Neck Surg 2021; 7:174-178. [PMID: 34094629 PMCID: PMC8164470 DOI: 10.1016/j.wjorl.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/05/2021] [Indexed: 12/01/2022] Open
Abstract
Adenotonsillectomy is one of the most common surgical procedures performed by otolaryngologists. It is vital that surgeons are aware of the risks in performing this surgery especially during the COVID-19 pandemic and in children with hematologic disorders. In this review we describe common hematologic disorders often noted in pediatric patients undergoing this procedure, as well as proper screening and management of these patients. In addition, we also address the impact of the COVID-19 pandemic and some measures to help mitigate the risks of this procedure during this time.
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Affiliation(s)
- Ryan Ruiz
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia 19104, USA
| | - Kavita Dedhia
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia 19104, USA
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6
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Low VWF levels in children and lack of association with bleeding in children undergoing tonsillectomy. Blood Adv 2021; 4:100-105. [PMID: 31905240 DOI: 10.1182/bloodadvances.2019000992] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023] Open
Abstract
von Willebrand disease is a common bleeding disorder, but diagnosis can be difficult in young children who have not had bleeding challenges. We sought to evaluate the correlation between bleeding and von Willebrand factor (VWF) levels in children undergoing surgical challenge with tonsillectomy. Children ages 0 to 18 undergoing tonsillectomy without a personal or family history of bleeding were enrolled prospectively following informed consent and institutional review board approval. VWF levels were obtained at the time of surgery. VWF antigen (VWF:Ag) and VWF activity (VWF:GPIbM) were tested via enzyme-linked immunosorbent assay. Bleeding score was calculated using the International Society of Hematology bleeding assessment tool (BAT). Surgical and postoperative bleeding were determined using questionnaires filled out by the surgeon and patient/family. A total of 1399 subjects were enrolled with evaluable data, with a median age of 5 years. The median VWF:Ag was 85 IU/dL and the median VWF:GPIbM was 100 U/dL. Median BAT for the entire population was 0, including those with postoperative bleeding. There was no difference in VWF level between those who experienced postoperative bleeding and those who did not, with median VWF:Ag 85 vs 85 (P = .89) and mean VWF:GPIbM 98 vs 100 (P = .5). Interestingly, there was a difference in VWF levels with age, with median VWF:Ag 81 for those younger than 3 years, 82 for those 3 to 6 years, 90 for those 7 to 10 years, and 100 for those 11 to 18 years. A similar trend was noted for VWF:GPIbM. Of the 2 to 6 year olds, 5% had VWF:Ag <50, which would meet criteria for low VWF, but only 1.8% had an abnormal BAT at study entry and only 2.5% bled after surgery. Only 1 subject with low VWF had an elevated postoperative BAT >2. These data suggest that low VWF levels do not correlate with bleeding in children undergoing tonsillectomy. In addition, VWF levels outside the adult normal range in young children may be more common than previously thought and do not necessarily predict surgical bleeding.
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7
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Chorney SR, Weinberger R, Weintraub AY, Buzi A. Post-Tonsillectomy Hemorrhage and the Diagnosis of Occult Pediatric Coagulopathies. Laryngoscope 2020; 131:E2069-E2073. [PMID: 33146421 DOI: 10.1002/lary.29244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/21/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES/HYPOTHESIS The primary objective of this investigation was to determine rates of abnormal coagulation panels and diagnoses of coagulopathies in children with post-tonsillectomy hemorrhage (PTH). Secondary objectives identified patient demographics and hemorrhage event characteristics that correlated with a coagulopathy diagnosis. STUDY DESIGN Case series with chart review. METHODS Patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 were included. Details of tonsillectomy procedures and hemorrhage events were reviewed along with screening labs for coagulopathy, referrals to hematology and bleeding disorder diagnoses. RESULTS There were 250 children included. Mean age was 8.8 years (95% CI: 8.2-9.4) and 53.6% were males. PTH events occurred at a median of postoperative day six (mean: 5.9, 95% CI: 5.4-6.3), and 14.8% occurred within 24 hours of surgery. In this series, 23 patients (9.2%) had a second PTH, and three (1.2%) had a third PTH. Single and multiple PTH patients were similar with respect to age, gender, postoperative day, and technique (P > .05). Screening coagulation panels were obtained on presentation in 67.8% of children with one PTH and abnormally elevated in 38.3%. All children with multiple PTHs had labs drawn with 34.8% having elevated levels. No child with a single PTH was diagnosed with a bleeding disorder. Conversely, 87.0% of children with multiple PTHs saw hematology and three (13.0%) were diagnosed with a bleeding disorder (P < .001). CONCLUSIONS Obtaining coagulation panels in pediatric patients presenting with PTH is rarely useful and diagnosing a coagulopathy is uncommon. However, among children with a second PTH, referral to hematology is reasonable as this group has a significantly higher, albeit small, incidence of undiagnosed bleeding disorders. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2069-E2073, 2021.
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Affiliation(s)
- Stephen R Chorney
- Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Rena Weinberger
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Ari Y Weintraub
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.,Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Adva Buzi
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A.,Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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8
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Baghaie H, Forrest B, Shukla K, Liu T. Dental extraction in a patient with undiagnosed Von Willebrand's Disease: a case report. Aust Dent J 2020; 66:105-111. [PMID: 33616961 DOI: 10.1111/adj.12788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 11/30/2022]
Abstract
Dental extractions are a common part of general dental practice. While dentists routinely screen for medical contraindications during the preoperative assessment, undiagnosed coagulopathies have the potential to severely complicate a seemingly routine extraction. We report a case of surgical removal of a mandibular third molar in a patient with undiagnosed Von Willebrand Disease.
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Affiliation(s)
- H Baghaie
- School of Dentistry, The University of Queensland, Herston, Queensland, Australia.,School of Medicine, Griffith University, Southport, Queensland, Australia
| | - B Forrest
- School of Medicine, Griffith University, Southport, Queensland, Australia
| | - K Shukla
- School of Medicine, Griffith University, Southport, Queensland, Australia.,Private Practice, Gold Coast, Queensland, Australia
| | - T Liu
- School of Dentistry, The University of Queensland, Herston, Queensland, Australia.,Oral and Maxillofacial Unit, Gold Coast University Hospital, Southport, Queensland, Australia
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Prevalence of Post-Tonsillectomy Hemorrhage in Adults and Children. JOURNAL OF CLINICAL AND BASIC RESEARCH 2020. [DOI: 10.52547/jcbr.4.2.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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Malhotra U, Hasday M, Romanos GE, Javed F. Assessment of routine diet (garlic consumption) as a pre- and postoperative protocol in oral and maxillofacial surgical interventions: An evidence-based literature review. Nutr Health 2020; 26:135-139. [PMID: 32241225 DOI: 10.1177/0260106020912940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It was hypothesized that pathological bleeding (PB) during and/or after oral surgical procedures is higher in systemically healthy patients who have a history of garlic intake compared to controls (patients without a history of garlic consumption). AIM The aim of the present review article was to identify studies in which garlic consumption was included as a patient management protocol before and after oral and maxillofacial surgery (OMFS). METHODS A review of pertinent indexed literature was performed. The focused question that was addressed was "Has diet (garlic consumption) been considered as a patient management protocol before and after OMFS?" The inclusion criteria were: (a) studies published in indexed databases, (b) original studies, (c) studies on OMFS, and (d) studies that considered diet (garlic consumption) as a patient management protocol before and after OMFS. Literature review, commentaries, letters to the editor, and studies published in non-indexed resources were excluded. The pattern of the present review was customized to summarize the pertinent information. RESULTS The initial search using the terms "oral," maxillofacial," "protocol," and "surgery" yielded 1478 studies. The addition of the term "diet" to this search strategy reduced the number of studies to five. Further filtration of these studies using the terms "garlic" and/or "Allium sativum" showed no studies. CONCLUSIONS Garlic intake predisposes patients to PB. However, there are no studies in the indexed literature that have considered the inclusion of garlic consumption in patient management protocols before and after OMFS.
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Affiliation(s)
- Upasna Malhotra
- Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Matthew Hasday
- Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Georgios E Romanos
- Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA.,Department of Oral Surgery and Implant Dentistry, Dental School, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Fawad Javed
- Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA.,Division of Orthodontics and Dentofacial Orthopedics, Eastman Institute for Oral Health, University of Rochester, NY, USA
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