Haemorrhagic complications remain a challenge with surgical procedures in patients with bleeding disorders. In children and young adults, the most commonly performed surgeries are tonsillectomies and/or adenoidectomies. Adequate haemostasis in these patients with bleeding disorders is centred on comprehensive perioperative haemostatic support and dexterous surgical technique. The aim of this study was to assess postoperative bleeding complications with tonsillectomy and/or adenoidectomy in children and young adults with known bleeding disorders. Retrospective review of all patients aged <25 years with known bleeding disorders who underwent tonsillectomy and/or adenoidectomy at Mayo Clinic, Rochester MN between July 1992 and July 2012. In contrast to reported literature, we observed a higher rate of bleeding complications (10/19, 53%) despite aggressive haemostatic support and appropriate surgical techniques. Delayed bleeding (>24 h postoperatively) was more common than early bleeding; and recurrent bleeding was associated with older age. Children and young adults with haemorrhagic diatheses undergoing adenotonsillectomy are at a higher risk of delayed bleeding and require close monitoring with haemostatic support for a prolonged duration in the postoperative period. A uniform approach is needed to manage these patients perioperatively by establishing standard practice guidelines and ultimately reduce postsurgical bleeding complications.

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Introduction Warfarin-induced skin necrosis is a rare but catastrophic complication of warfarin therapy, ranging in prevalence from 0.01% to 0.1%. This case report discusses a case of warfarininduced skin necrosis. Case reportWe report the case of an obese, 55-year-old woman who presented with extensive skin necrosis of the left lower limb on the fifth day of warfarin therapy and responded well with early diagnosis and treatment. Discussion Warfarin-induced skin necrosis is the result of a relatively hypercoagulable state produced by warfarin. Warfarin-induced skin necrosis typically occurs in obese, perimenopausal women of around 50 years of age with high loading doses of warfarin. Warfarin-induced skin necrosis typically involves skin and subcutaneous tissue overlying areas with significant adipose tissue, such as the breast, abdomen, thigh or buttocks. It presents within three to six days after beginning therapy. Conclusion Prevention and management of warfarin-induced skin necrosis in a timely manner should be emphasised to prevent permanent tissue damage. A more gradual approach using low initial dose and gradual increase in daily doses is believed to reduce the risk of warfarin-induced skin necrosis.

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