Anna Gorzelnik, *Lidia Zawadzka-Głos, Agnieszka Segiet, Karolina Raczkowska-Łabuda
Hemorrhage risk factors assessment in pediatric patients undergoing adenoidectomy/adenotonsillotomy
Ocena czynników ryzyka krwawienia u dzieci po adenotomii/adenotonsillotomii
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Wstęp. Krwotok jest jedną z najpoważniejszych komplikacji adenotomii (AT) i adenotonsillotomii (ATT) u dzieci. Nieuzyskanie hemostazy jest wskazaniem do założenia tamponady Bellocqa. W celu zminimalizowania ryzyka krwawienia pooperacyjnego wykonuje się badania układu krzepnięcia, morfologię i oznaczanie grupy krwi.
Materiał i metody. Analizowano dane 135 dzieci po zabiegu AT/ATT o prawidłowych parametrach układu krzepnięcia przed operacją. Do grupy badawczej włączono dzieci, które wymagały tamponady tylnej nosa (N = 41), a do grupy kontrolnej – dzieci z krwotokiem z nosa, który ustąpił samoistnie i nie wymagał tamponady, lub dzieci bez krwotoku z nosa (N = 94).
Wyniki. Wykazano, że krwotok częściej występował u starszych dzieci. Nie stwierdzono związku między grupą krwi, wiekiem, płcią, typem zabiegu i parametrami badań laboratoryjnych wykonanymi przed zabiegiem a częstością krwotoku.
Wnioski. W naszym badaniu wyniki badań laboratoryjnych wykonanych przed zabiegiem nie były dobrym predyktorem ryzyka krwotoku po AT/ATT. Jednak szczegółowe zebranie wywiadu osobistego i rodzinnego, dokładne badanie przedmiotowe oraz odpowiednie zaplecze laboratoryjne mogą ujawnić skazy krwotoczne o dotychczas bezobjawowym przebiegu klinicznym.
Summary
Introduction. Hemorrhage is one of the most important complication of adenoidectomy (AT) and adenotonsillotomy (ATT) in children. The lack of hemostasis is an indication for Bellocq’s tamponade. Preoperative coagulation tests, complete blood count and blood type tests are taken to minimize the risk of bleeding after surgery.
Material and methods. Data of 135 children with preoperative normal bleeding tests who underwent AT/ATT was collected. In study group (N = 41), postoperative hemorrhage requiring posterior nasal pack occurred. In the control group (N = 94), bleeding after AT/ATT resolved spontaneously and did not require nasal packing.
Results. Hemorrhage was associated with older age. There was no relationship between hemorrhage and blood group, gender, type of the procedure and laboratory results obtained before the surgery.
Conclusions. In our study, preoperative laboratory findings failed to effectively identify the patients at risk of hemorrhage after AT/ATT. However, a thorough medical interview and family history, as well as a detailed physical examination and laboratory testing might reveal bleeding disorders that had been asymptomatic.
Introduction
Hemorrhage is a serious complication after adenoidectomy (AT) and adenotonsillotomy (ATT) in children. It usually occurs in the first 24 hours after the procedure (1-4). The reason for the lack of appropriate hemostasis should be sought in an incomplete removal of the tonsil tissue, inadequate perioperative and postoperative care, as well as in previously unrecognized coagulation disorders. Prolonged heavy intraoperative or postoperative bleeding with an insufficient response to conservative management are an indication for the introduction of the Bellocq tampon to the nasopharynx in order to apply pressure to the bleeding vessel. In this case, the patient always requires hospitalization and antibiotic prophylaxis. In order to minimize the risk of postoperative bleeding, it is becoming a standard to perform complete blood count, ESR (erythrocyte sedimentation rate), blood group, activated partial thromboplastin time (APTT), and prothrombin time (PT) in the preoperative period.
Aim
The aim of the study was to assess the predictive value of the measured parameters on the risk of hemorrhage in children undergoing AT/ATT.
Material and methods
A retrospective analysis of patients after AT/ATT was performed. The patients did not have prolonged APTT or PT before the procedure. The patients were hospitalized in the Department of Pediatric Otolaryngology of the Medical University of Warsaw from Jan 2008 to Dec 2014. The patients were assigned to one of the two groups: patients with nasopharyngeal hemorrhage requiring posterior epistaxis (study group), and patients with nasopharyngeal hemorrhage that had not required posterior epistaxis or patients without hemorrhage (control group). The groups were compared in terms of blood group, age, sex, type of surgery, coagulation parameters (APTT, INR – international normalized ratio), ESR, and full blood count (WBC – white blood count, PLT – platelet count, %Lymph – lymphocyte percentage, %Mono – monocyte percentage, %Neu – neutrophil percentage).
In descriptive statistics for categorical variables, the number and percentage of occurrences were taken into account. The distribution of continuous variables was first evaluated using the Shapiro-Wilk test, then, in case of variables with normal distribution, mean and standard deviation were calculated, otherwise median and the 25th and 75th percentile were reported. For each variable, the number of missing data was given. Categorical variables were compared using the Fisher test or chi-squared test, depending on the size of the categories. Normally distributed variables were compared with the Student’s t-test, otherwise the Mann-Whitney test was used.
The predictive capacity of the variables as predictors of hemorrhage requiring tamponade was investigated using ROC curves. For each variable, the AUC (area under the curve) was given, together with the 95% confidence interval, cutoff point corresponding to the value of the variable for which the distance of the ROC curve from the point (100%, 100%) was minimal, as well as the sensitivity and the specificity at the selected cutoff point.
In all the analyzes, the level of statistical significance 0.05 was assumed.
Results
Data of 135 patients was collected. 41 patients were included in the study group, and 94 – to the control group.
As shown in table 1, there were no statistically significant differences in coagulation parameters and blood count between the groups. The identified factors affecting the onset of a hemmorhage requiring tamponade included age (median age was significantly higher in the study group than in control group) and myringostomy performed at the same time (in study group, myringostomy was performed significantly rarelier than in control group. No statistically significant differences in the gender distribution or Rh blood group were found.
Tab. 1. The characteristics of the study group and the control group. SD – standard deviation; IQR – interquartile range; APTT – activated partial thromboplastin time; INR – international normalized ratio; ESR – erythrocyte sedimentation rate; WBC – white blood count; PLT – platelets; %Lymph – lymphocyte percentage; %Neu – neutrophil percentage; %Mono – monocyte percentage; AT – adenoidectomy; ATT – adenotonsillotomy
| Variable | Category | Total | Control group | Study group | Missing data | p-value |
| N | | 135 | 94 | 41 | | |
| Sex (%) | K | 64 (47.4) | 40 (42.6) | 24 (58.5) | 0 (0.0%) | 0.128 |
| | M | 71 (52.6) | 54 (57.4) | 17 (41.5) | | |
| Age: median [IQR] | | 6.0 [4.0, 8.0] | 6.0 [4.0, 7.0] | 7.0 [5.0, 12.0] | 0 (0.0%) | 0.025* |
| Procedure (%) | AT | 80 (59.3) | 56 (59.6) | 24 (58.5) | 0 (0.0%) | >0.999 |
| | ATT | 55 (40.7) | 38 (40.4) | 17 (41.5) | | |
| APTT: mean (SD) | | 32.9 (3.9) | 32.8 (4.0) | 33.2 (3.5) | 11 (8.1%) | 0.635 |
| INR: mean (SD) | | 1.1 (0.08) | 1.1 (0.08) | 1.1 (0.06) | 12 (8.9%) | 0.383 |
| OB: median [IQR] | | 9.0 [5.5, 13.0] | 8.5 [5.8, 13.0] | 9.0 [5.5, 14.5] | 24 (17.8%) | 0.787 |
| WBC: median [IQR] | | 7.8 [6.5, 9.4] | 7.9 [6.5, 9.6] | 7.6 [6.7, 8.7] | 16 (11.9%) | 0.655 |
| PLT: median [IQR] | | 298.0
[263.5, 354.5] | 298.0
[268.0, 371.0] | 299.0
[263.2, 342.0] | 16 (11.9%) | 0.829 |
| %Lymph: median [IQR] | | 41.2 [34.1, 47.9] | 42.6
[35.5, 48.2] | 35.8
[33.8, 45.3] | 27 (20.0%) | 0.077 |
| %Neu: mean (SD) | | 45.6 (11.5) | 44.9 (11.0) | 47.7 (13.0) | 27 (20.0%) | 0.324 |
| %Mono: median [IQR] | | 7.9 [6.7, 9.1] | 7.8 [6.6, 9.1] | 7.9 [6.9, 8.8] | 40 (29.6%) | 0.789 |
| APTT – normal/low/high(%) | low | 11 (8.9) | 9 (9.7) | 2 (6.5) | 11 (8.1%) | 0.884 |
| | normal | 109 (87.9) | 81 (87.1) | 28 (90.3) | | |
| | high | 4 (3.2) | 3 (3.2) | 1 (3.2) | | |
| INR – normal/low/high (%) | low | 1 (0.8) | 1 (1.1) | 0 (0.0) | 12 (8.9%) | >0.999 |
| | normal | 121 (98.4) | 91 (97.8) | 30 (100.0) | | |
| | high | 1 (0.8) | 1 (1.1) | 0 (0.0) | | |
| OB – normal/low/high(%) | low | 0 (0.0) | 0 (0.0) | 0 (0.0) | 24 (17.8%) | 0.918 |
| | normal | 71 (64.0) | 57 (64.8) | 14 (60.9) | | |
| | high | 40 (36.0) | 31 (35.2) | 9 (39.1) | | |
| WBC – normal/low/high(%) | low | 1 (0.8) | 1 (1.1) | 0 (0.0) | 16 (11.9%) | 0.657 |
| | normal | 97 (81.5) | 74 (79.6) | 23 (88.5) | | |
| | high | 21 (17.6) | 18 (19.4) | 3 (11.5) | | |
| PLT – normal/low/high (%) | low | 0 (0.0) | 0 (0.0) | 0 (0.0) | 22 (16.3%) | 0.333 |
| | normal | 6 (5.3) | 6 (6.9) | 0 (0.0) | | |
| | high | 107 (94.7) | 81 (93.1) | 26 (100.0) | | |
| %Lymph - normal/low/high(%) | low | 4 (3.7) | 2 (2.4) | 2 (7.7) | 27 (20.0%) | 0.230 |
| | normal | 66 (61.1) | 49 (59.8) | 17 (65.4) | | |
| | high | 38 (35.2) | 31 (37.8) | 7 (26.9) | | |
| %Neu - normal/low/high(%) | low | 42 (38.9) | 32 (39.0) | 10 (38.5) | 27 (20.0%) | 0.737 |
| | normal | 61 (56.5) | 47 (57.3) | 14 (53.8) | | |
| | high | 5 (4.6) | 3 (3.7) | 2 (7.7) | | |
| %Mono - normal/low/high(%) | low | 2 (2.1) | 1 (1.4) | 1 (3.8) | 40 (29.6%) | 0.517 |
| | normal | 53 (55.8) | 40 (58.0) | 13 (50.0) | | |
| | high | 40 (42.1) | 28 (40.6) | 12 (46.2) | | |
| Blood group (%) | 0 Rh - (minus) | 5 (3.8) | 2 (2.2) | 3 (7.5) | 3 (2.2%) | 0.217 |
| | 0 Rh + (plus) | 28 (21.2) | 18 (19.6) | 10 (25.0) | | |
| | A Rh - (minus) | 9 (6.8) | 7 (7.6) | 2 (5.0) | | |
| | A Rh + (plus) | 55 (41.7) | 35 (38.0) | 20 (50.0) | | |
| | AB Rh - (minus) | 4 (3.0) | 4 (4.3) | 0 (0.0) | | |
| | AB Rh + (plus) | 8 (6.1) | 8 (8.7) | 0 (0.0) | | |
| | B Rh - (minus) | 5 (3.8) | 4 (4.3) | 1 (2.5) | | |
| | B Rh + (plus) | 18 (13.6) | 14 (15.2) | 4 (10.0) | | |
| Blood group ABO (%) | A | 64 (48.5) | 42 (45.7) | 22 (55.0) | 3 (2.2%) | 0.034* |
| | B | 23 (17.4) | 18 (19.6) | 5 (12.5) | | |
| | AB | 12 (9.1) | 12 (13.0) | 0 (0.0) | | |
| | 0 | 33 (25.0) | 20 (21.7) | 13 (32.5) | | |
| Blood group Rh (%) | Rh - (minus) | 23 (17.4) | 17 (18.5) | 6 (15.0) | 3 (2.2%) | 0.815 |
| | Rh + (plus) | 109 (82.6) | 75 (81.5) | 34 (85.0) | | |
| Myringostomy (%) | No | 99 (73.3) | 63 (67.0) | 36 (87.8) | 0 (0.0%) | 0.021* |
| | Yes | 36 (26.7) | 31 (33.0) | 5 (12.2) | | |
| Concomittant diseases (%) | Yes | 66 (51.2) | 44 (46.8) | 22 (62.9) | 6 (4.4%) | 0.155 |
| | No | 63 (48.8) | 50 (53.2) | 13 (37.1) | | |
*p-values of statistical significance p < 0.05
The percentage of patients suffereing from concomitant diseases was compared. A statistically significant difference was observed only in the case of chronic serous otitis media, which was significantly less frequent in the study group (0.0%) than in the control group (17.0%) (p = 0.003).
The area under the ROC curves (AUC) for the considered variables amounted to ca. 50-60% (95% CI in the range of 40-70%) (tab. 2).
Tab. 2. The assessment of the predictive power of the considered variables as predictors of nasopharyngeal hemorrhage requiring posterior epistaxis – the analysis of the ROC curves. APTT – activated partial thromboplastin time; INR – international normalized ratio; ESR – erythrocyte sedimentation rate; WBC – white blood count; PLT – platelets; %Lymph – lymphocyte percentage; %Neu – neutrophil percentage; %Mono – monocyte percentage
| Variable | AUC [%] | 95% CI [%] | Cut-off | Specificity [%] | Sensitivity [%] |
| Age | 62.1 | 51.6-72.7 | 6.5 | 62.8 | 53.7 |
| APTT | 52.1 | 40.7-63.6 | 32.1 | 51.6 | 61.3 |
| INR | 55.6 | 44.7-66.6 | 1.1 | 43.0 | 76.7 |
| OB | 51.9 | 38.3-65.4 | 9.5 | 61.4 | 47.8 |
| WBC | 52.9 | 40.9-64.8 | 8.2 | 45.2 | 65.4 |
| PLT | 48.6 | 36.6-60.6 | 306.5 | 57.0 | 50.0 |
| %Lymph | 61.6 | 49.0-74.1 | 38.2 | 69.5 | 61.5 |
| %Neu | 56.5 | 43.3-69.7 | 48.2 | 62.2 | 50.0 |
| %Mono | 51.8 | 38.4-65.3 | 8.2 | 63.8 | 46.2 |
In 8 out of 41 patients who had undergone AT/ATT and had required posterior epistaxis, additional diagnostics of the coagulation system was performer and a control at a hematology clinic was advised. 2 patients were diagnosed with coagulation disorders (one case of factor VII deficiency and one case of von Willebrand disease). Two children were found to have a borderline low score of one of the coagulation factors that did not allow the diagnosis of a purpura, but indicated the need for hematological care. In 3 children who underwent the additional diagnostics no abnormal results were found (5).
Discussion
AT/ATT is frequently the first surgical intervention in a child’s life, therefore, there is a good chance of detecting coagulation disorders that have been asymptomatic (6, 7). For this reason, preoperative coagulation tests are routinely performed (8).
The indications for a more detailed hematological diagnostics include both the abnormal coagulation test results, as well as a positive history of bleeding disorders (9-11). In the study by Close (12), the history of 6 out of 96 studied children raised the suspicion of a bleeding disorder. One of this patient was subsequently diagnosed with von Willebrand disease.
In the study by Schenckenbach (13), 0.9% of all patients were diagnosed with a purpura during the preoperative AT/ATT coagulation tests. Bhasin (14) compared the predictive power of the laboratory coagulation tests with a history of bleeding (N = 792). Clinically significant coagulation abnormalities were observed in 4% of patients (N = 32). Positive personal or family history was present in 33.8% of all the patients (14). In 53.1% of patients with clinically significant bleeding disorders, positive history was present (N = 17) (14). It must be, however, underlined, that the collected history should include not only family and personal predisposition to bleeding, but also diseases and medications that may affect the coagulation process (15).
Many researchers underline the small predictive power of the laboratory tests. In a group of 1137 children after ATT, 3% had abnormal coagulation tests (thrombocytopenia, prologed PT, anemia), and only 0.12% of patients were disqualified from the surgery (16). Postoperative hemorrhage was observed in 11 patients without abnormalities in preoperative studies (16). Similarly, in an analysis on 4373 patients after AT/ATT, no coagulation disorders were found in any of the 43 patients with postoperative hemorrhage (17). Our analysis also does not confirm that laboratory tests are good predictors for bleeding after AT/ATT. Moreover, our results suggest that myringostomy reduced the risk of hemorrhage, which is probably due to the need for longer nasopharynx hemostasis during the procedure. No proves of such relationship were found in the literature.
Age appears to be an important risk factor. In an analysis by Kshirsgar (18), a correlation between the risk of bleeding and age, as well as obesity, was found. No correlation between the risk of bleeding and sex was found. Harounian (19) also reports that the highest rate of bleeding after ATT occurred in the age group between 11 and 17 years, and the lowest – in the age group between 1 and 3 years. The reason for this may include greater postoperative wound and a greater diameter of arteries and veins at the surgical site in older children.
Conclusions
Performing coagulation test, full blood count, and blood group test prior to AT/ATT in children should be the gold standard for detecting patients with coagulation disorders before the surgery.
In order to minimize the risk of a hemorrhage after AT/ATT, it is essential to collect a detailed personal and family history, perform an accurate physical examination, and appropriate laboratory tests.
Age seems to be an important risk factor for a hemorrhage after AT/ATT.
Mild bleeding disorders (especially von Willebrand disease) may first occur during AT/ATT due to the previously asymptomatic clinical course.
Piśmiennictwo
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