Emergency medicine providers’ experience with posttonsillectomy hemorrhage in the emergency department

Tonsillectomy is a common pediatric surgical procedure in the United States, encompassing 289,000 surgeries annually in children <15 years old.1 Although this surgery has overall low morbidity, up to 5% of patients experience a secondary posttonsillectomy hemorrhage (PTH), or bleeding greater than 24 h postoperatively.2, 3 PTH varies in presentation from mildly darkened oral secretions to active hemoptysis or hematemesis, leading to emergency department (ED) visits, hospital readmissions, blood transfusions, surgical interventions, and even rarely, death. ED management of PTH can be very challenging; the airway is often difficult to visualize and/or inaccessible, making direct pressure or medication application impractical. Gargles, silver nitrate, and topical agents have yielded unsatisfactory results, and there are limited best practice guidelines in the ED.4-6 Nebulized tranexamic acid (TXA) is a potential noninvasive way to control hemorrhage; equally appealing is its ease of administration and wide availability. A growing body of literature has been published regarding the efficacy of nebulized TXA for PTH. A 2021 retrospective cohort study demonstrated a 44% reduction in secondary operations with no adverse events.7 Three subsequent retrospective studies have found similar reductions in PTH.2, 8, 9 The largest study to date demonstrated an operative reduction rate from 60.2% to 36.1% and bleeding reduction rate from 14.2% to 4.9%.2 Nebulized TXA has successfully decreased the need for invasive procedures to control upper airway bleeding in children with PTH. Considering the increasing relevance of nebulized TXA in the literature, this survey study aims to evaluate the current trends and management strategies for PTH by emergency medicine providers. A survey study was conducted of emergency medicine providers to evaluate the current trends and management of PTH. Survey development included a team of pediatric emergency medicine, pediatric critical care, and pediatric otolaryngologist (ENT) specialists. A survey expert evaluated the pretest followed by survey distribution to emergency medicine providers in a pilot test. The final version of the survey was distributed on PED-EM-L (https://listserv.brown.edu/cgi-bin/wa?A0=PED-EM-L), a listserv commonly used by pediatric emergency medicine providers to discuss specialty related topics. This listserv has approximately 3000 subscribers, the population of which is not well defined. The survey was distributed twice over the listserv, 2 weeks apart. Survey completion was voluntary, with no incentives offered for participation. The survey was deemed not human subjects research by the institutional review board at the University of Texas Health Science Center at San Antonio (STUDY00000215). Survey response was collected and managed using Research Electronic Data Capture (REDCap). Deidentified data was then exported into Microsoft Excel. Statistical analysis was performed using JAMOVI with Fisher's exact testing. There were 157 total respondents; 23 were excluded (10 were not pediatric emergency medicine fellowship or emergency medicine residency trained; an additional 13 did not manage a pediatric PTH within 6 months of questioning), leaving a total of 134 responses who completed the survey. When asked to select from a list of (non–mutually exclusive) definitions of PTH, respondents reported active bleeding (98.5%), return to the operating room (81.3%), history of bleeding at home (68.7%), clot on the tonsillar fossa (68.7%), and blood-tinged secretions without bleeding on examination (57.5%). The most common interventions attempted by ED providers for PTH (independent of ENT recommendations) in the prior 6 months were nebulized TXA (65.7%), followed by observation (55.2%) and intravenous TXA (31.1%). The most self-perceived effective management strategies for PTA (effective or very effective on a 5-point Likert scale) were nebulized TXA (64.5%), intravenous TXA (44.2%), and topical or epinephrine-soaked pledgets (37.2%; Figure 1). When asked about outcomes in the ED, 23.9% of respondents reported patients with PTH rarely going to the OR from the ED, followed by 44% going sometimes (10% to <50% of the time) and 24.6% going most of the time (50%–99%). There was no association between going to the OR and use of nebulized TXA (p = 1.0), which was decided by the ENT team and not the ED provider. Most respondents’ institutions did not have clinical practice guidelines for the management of PTH (73.1% none, 10.4% unsure). Availability of a clinical practice guideline was not associated with use of nebulized TXA (p = 0.808). There were a variety of respondents, including 72.4% in primary academic settings. Practice setting (academic vs. nonacademic) was not associated with use of nebulized TXA (p = 0.314). Practice setting did not affect presence of clinical practice guideline (p = 0.427). The survey revealed that 65.7% of providers saw between one and five PTH per month; 14.9% saw <1/month and another 14.2% saw 6–10/month. The average number of PTH per month a provider managed was not associated with nebulized TXA use (p = 0.492). Of the respondents, 26.1% were <5 years postgraduate training and 54.5% were more than 10 years postgraduate training. There was statistical significance between use of nebulized TXA and <5 years post-graduate training (p = 0.004), but not more than 10 years (p = 0.071). Most providers had access to pediatric-specific otolaryngologists (81.3%); 69.4% had access to in-person consult available within ≤30 minutes of answered call/page. There was no difference between ENT availability and use of nebulized TXA (no ENT p = 0.343; general ENT p = 0.844; pediatric ENT p = 0.254; phone consults p = 0.573; in-person consult ≤30 min p = 0.698; in-person consult >30 min p = 0.417). Approximately 12% of providers had transported a PTH to another facility within the prior 6-month period. Transportation to another hospital was not associated with use of nebulized TXA (p = 0.053). Prior to 2018, there was no literature on the use of nebulized TXA for secondary PTH in the pediatric population.10 Since then, there has been increasing evidence demonstrating that nebulized TXA is effective in reducing the severity of PTH.2, 7-9 This study highlights emergency medicine providers’ willingness to use, and their self-perceived effectiveness of, nebulized TXA as a treatment modality, especially for those closer to postgraduate training. The sparsity of PTH clinical practice guidelines suggest the need for more robust data to formulate better ED management strategies. This is especially important as nebulized TXA can reduce the need for operative intervention but only if in coordination with ENT providers with evidence-backed randomized, controlled studies. The lack of clear definition or grading system for PTH, as underscored in this study, may also be a contributing factor in the difficulty regarding appropriate treatment of PTH, including the decision of operative versus nonoperative management. The study was subject to selection bias given the convenience sample of the survey distribution and lack of comparative characteristics of the entire email distribution list. While the demographics and training experience of the entire email distribution list was unknown, there was variability in the respondents’ institution and provider types. In summary, given the recent increase in provider use of nebulized TXA, future prospective studies are needed to evaluate its role in the decision tree of PTH management, including its ability to potentially reduce bleeding, hospital transfers, readmissions, returns to the OR, and death. Whitney W. Schwarz: study design, acquisition of the data, interpretation of the data, drafting of manuscript. Amanda M. Lee: study design, review and revision of the manuscript. Andrew D.J. Meyer: study concept, study design, review and revision of the manuscript. Dylan Z. Erwin: study design, review and revision of the manuscript. Mark R. Zonfrillo: study design, acquisition of the data, review and revision of the manuscript. No funding was provided for this Research Letter. Grant money for investigator-initiated research: WWS, ADM, DZE report grant money to UT Health Science Center at San Antonio to conduct research conceived by WWS, ADM, DZE from University of Texas (received IRB approval, pending enrollment). The authors declare no conflicts of interest. UT Health IRB Approval was obtained to conduct this survey (STUDY00000215). The data that support the findings of this study are available from the corresponding author upon reasonable request.