Perioperative management in chronically anticoagulated children undergoing tonsillectomy.

Abstract

Tonsillectomy is a common procedure in children. Patients at high risk for thrombosis who require chronic anticoagulation therapy pose a special challenge when undergoing tonsillectomy, as bleeding may occur up to two weeks after surgery. Due to a lack of evidence-based data, there is no consensus on the best management for such patients. The objective of our manuscript is to review perioperative anticoagulation bridging strategies in children undergoing tonsillectomy. Retrospective case series of chronically anticoagulated patients at high risk for a thromboembolic event, who underwent tonsillectomy from 2010 to 2021. Patients whose anticoagulation treatment was discontinued due to a low risk of thromboembolic events were excluded. Four patients met inclusion criteria (age range 1.5-16.1 years). All patients were admitted prior to surgery for bridging therapy with intravenous unfractionated heparin (UFH) drip titrated to a therapeutic dose until 4-6 hours prior to surgery. The estimated blood loss during surgery was minimal in all surgeries. UFH was readministered per hospital protocol on the night of surgery and titrated to a therapeutic dose. Postoperative warfarin was restarted within 2 days for all patients. High-risk patients were kept in the hospital until postoperative day 6-8 due to concern for delayed bleeding. One patient was noticed to have blood-tinged sputum requiring no intervention, and none of the patients developed early or delayed hematemesis. Our data show that bridging therapy with UFH has been successful. Chronically anticoagulated patients undergoing tonsillectomy require multidisciplinary care for the management of their pre- and postoperative course.