Hi Heather
This thread is right up my alley since I am a retired ENT. I retired because I have a cardiac defibrillator, which did not fire for 12 years. When it did, that was the end of my surgical career. You do not want a surgeon operating on you or your child to pass out from ventricular fibrillation, or if not passing out ‘jerk’ when the defibrillator fires. My credentials are as follows, Harvard trained otolaryngologist, board certified, and I have never been sued during my 28-year surgical career.
I never performed a tonsillectomy on a patient taking Coumadin. I have operated on hemophiliacs and a patient with a bleeding disorder called Von Willebrands disease. Under all of these cases I worked closely with a board certified hematologist. All of the appropriate frozen blood products needed to correct the problem were stockpiled prior to the surgery. These patients stayed overnight rather than going home the day of surgery.
Your daughter presents a more complex problem. There seem to be several concerns regarding this procedure and the postoperative care. These are pain control and the related topic of eating and taking oral medications, the concept of bleeding, and finally the management of bridging therapy with IV heparin until the INR is backing range. Let me discuss each in order.
Pain control involves not only the choice of pain medications but also the technique by which the surgery is performed. Oral medications range from Tylenol and Motrin to combinations with potent narcotics such as codeine and hydrocodone. In addition, every patient is different. The same surgeon performing the same technique will have patients that eat a full regular meal as soon as they get home from the hospital to those that come back in for several days on IV fluids and refuse to eat at all. (My technique for dealing with these patients was to come into the room and tell the child, “You have to drink”. When they didn’t, I would say, “Well, if you won’t drink, then I’m turning the television off. When you start drinking we will let you watch it.”)
The ENT medical literature is filled with different medical therapies and surgical techniques to reduce pain. The use of intraoperative antibiotics and steroids in some studies reduces poet operative pain. Many of the surgical techniques are supported by the equipment manufacturers that sell single use disposable devices that add $200 to the cost of the procedure. For many hospitals that receive a fixed amount of money from the insurance companies for the procedure and total care, this increase in costs is often the difference between making a profit or losing money. (A nun who headed one of my hospitals many years ago when talking of the Mission of the hospital to help the poor said,” If there is no money, there is no mission”.) So, what are the choices? All techniques use some sort of mechanism to cut, coagulate, and remove tissue. The tonsil itself does not have any pain fibers in it and it is damage to the surrounding muscular tissues on which the tonsil rests that causes pain. This trauma is most commonly related to thermal damage from the cautery of bleeding vessels. Many years ago, tonsils were removed with sharp curved scalpels and the bleeding controlled with ‘slip knot’ absorbable sutures. There is lots of anecdotal evidence that these patients had much less pain then current techniques. However, the blood loss was very significant, and in a 30 lb child often left them weak and tired for several weeks. Historically this lead surgeons to start using cautery techniques to both remove the tonsil and reduce the blood loss simultaneously. Unfortunately, this increased the level of pain markedly. Thus there was a good aspect and a bad aspect of the techniques. A technique called “Coblation” used radiofrequency to focus the energy on the tonsil but reduce heat energy to surrounding tissue was developed. A massive advertising campaign in the lay magazines lead to mothers coming into the office, waving the articles and demanding this new technique. The hot new rage is called a partial intracapsular tonsillectomy. This seems to be done with a microdebrider and spot cautery during the procedure. There is a learning curve to this technique and it is unreasonable to expect a surgeon with little or no experience to learn on a Coumadin patient. Along this same line is the fact that while the operation is effective for airway obstruction from enlarged tonsils, the jury is out as to whether it is effective for recurrent infections since a portion of the tonsil is left in place.
Next lets discuss bleeding. There is intraoperative bleeding, postoperative bleeding, and delayed bleeding. Intraoperative bleeding is under the direct visualization of the surgeon and responds to usual control measures. Postoperative bleeding occurs within the first several hours after surgery, usually when the patient is still in a medical care facility. (However, some out patient facilities have tried discharging patients within 1-2 hours of the completion of surgery). Finally there is delayed bleeding. Statistically this occurs usually between the third and tenth day after surgery. Longer periods are described in the literature, and I had an adult who bled on the 34th day post operative. The incidence of bleeding in the literature ranges from between 1-4%. (Any ENT who says that they have never had a bleeder is either a liar or hasn’t done very many. My bleeding rate over my career was slightly less over 2% and I never had to transfuse a patient or am I aware of any doctor in my surrounding communities that had to transfuse a patient.) The degree of bleeding ranges from spitting up 1-2 teaspoons of blood which stops spontaneously, several cups of blood which requires control either with local anesthesia in the examining chair or returning to the operating room for control. Finally, the amount and rapidity of blood loss can result in death. The figures for that risk are that there are somewhere between 400,000 and 600,000 tonsillectomies done each year with a death rate of 250-800. There is some evidence to show that sucking on 'popsicles' as soon as possible after surgery and as frequently as possible decreases the time to resumption of diet and may prevent monor bleeding.
Finally there is the question of bridging therapy. Assuming the ability to take oral Coumadin, the time on IV Heparin until the INR is back in therapeutic range should be 3-5 days. Thus staying in the hospital for 2 weeks will not help regarding bleeding and becasue of boredom, may delay healing. The concept of decreased activity and change in diet has been discussed elsewhere on this sight and has to be kept in mind. I would favor daily INR (I hope you have a home testing device).
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
I have always heard, young children do great when they have their tonsils removed...Not, like my daughter who was age 18..and not a heart patient. Lots of pain.
