(115) Impact of a Protocol on Pediatric Post-Tonsillectomy Hemorrhage Management

Introduction: Pediatric post-tonsillectomy hemorrhage (PTH) is a potentially serious complication that may require return to the operating room (OR). This study evaluated whether implementing a standardized protocol in a children’s hospital ED increases IV or nebulized tranexamic acid (TXA) use and reduces need for OR.

Methods: A retrospective and prospective study of pediatric patients ( < 18 years) presenting with PTH to the Children’s Hospital of Richmond ED was conducted. The pre-protocol cohort included patients from March 2022 to April 2024, and the post-protocol cohort included patients from May 2024 to March 2025. The intervention was a standardized ED protocol for PTH management, including IV or nebulized TXA and criteria for return to OR. Age, BMI percentile, post-operative day on presentation (POD), need for OR, and TXA administration were collected.

Results: 47 patients were included (pre: n = 18; post: n = 29). Age (7.9 vs. 8.0 years, p = 0.92), BMI percentile (65.4 vs. 63.9, p = 0.85), and POD (6.1 vs. 5.0, p = 0.32) were not statistically significant. Protocol implementation was associated with significantly reduced rates of returning to the OR (55.6% → 3.4%, RR 0.06, 95% CI 0.01–0.41; p < 0.001) and increased TXA use (IV and/or nebulized, 50% → 86.2%, RR 1.72, 95% CI 1.17–2.54; p = 0.0005).

Conclusions: Standardized ED management for pediatric PTH considerably decreased the need to return to the OR and increased IV/nebulized TXA administration. These improvements resulted in formal protocol implementation and reinforce evidence from prior studies supporting the national adoption of standardized protocols.