DEPARTMENT OF PAEDIATRIC ANAESTHESIA

WOMEN’S AND CHILDREN’S HOSPITAL

GUIDELINES FOR ANAESTHESIA FOR ELECTIVE TONSILLECTOMY

 1 Disease:

Lymphoid hyperplasia with or without superimposed infection

 2 Anaesthetic Problems:

• Shared airway
• Tonsillar disease may be associated with
• Upper airway obstruction
• Intercurrent upper respiratory sepsis
• Sleep apnoea
• Pulmonary hypertension (rarely)
• Surgical problems including haemorrhage into airway
• Post-operative nausea & vomiting
• Analgesia postoperatively in sleep apnoea patients

 3 Assessment:

• Age/Weight/Temperature
• Previous medical history including anaesthetic history (and family history)
• Recent URTIs
  • Cancel if fever/purulent discharge/septic tonsils/chest signs
• Symptoms of sleep apnoea
  • Snoring (non specific)
  • Apnoeic periods greater than 10 seconds
  • Day time somnolence (may not be obvious in children)
  • Failure to thrive
• Look out for
  • Obese or markedly underweight
  • Patients less than 3 years old
• Venous access
• Aspirin ingestion in preceding 2 weeks (NSAIDS have shorter half-life – check for individual drug)
• Investigations -only if indicated on history and/or examination  

 4 Premedication:

• Paracetamol 20mg/kg oral.
• EMLA if considering IV induction
• Preferably no sedatives.  

 5 Induction:

Inhalation OR intravenous- either reasonable
Inhalation may be better with obstructive sleep apnoea.

 6 Maintenance:

• Intubation with oral RAE ETT
• Spontaneous ventilation (O2/N2O/volatile) OR short acting non-depolarising muscle relaxant and IPPV
• Monitoring includes: pulse oximetry; ECG; NIBP;ETCO2; FIO2; agent.
• Intra-operative Analgesia:
  • Opioid at weight appropriate dose
• Antiemetics
  • Tropisetron IV (0.1- 0.2mg/kg up to a maximum dose of 2mg) and
  • Dexamethasone IV (0.15mg/kg up to a maximum of  8mg)
   

 7 Intra-operative Fluids:

All receive at least 10ml/kg balanced salt solution intra-operatively 

 8 Emergence:

Carefully suction pharynx under direct vision
Place in left lateral position
Extubate deep OR awake  at anaesthetist’s discretion

 9 Recovery:

On discharge from Recovery, the patient should be:

• Awake
• Protecting airway
• In minimal discomfort
• Not vomiting
• Not bleeding
• Have stable observations
• Have post-operative instructions by surgeons

 10 Post-Recovery Management:

Indications for admission to PICU:

• Severe obstructive sleep apnoea (OSA) with respiratory distress index (RDI) > 25 proven on sleep study
• Age < 2 yrs
• Morbid Obesity
• Failure to thrive
• Hypotonic disorder
• Cerebral palsy
• Cranio-facial abnormality
• Pulmonary HT/ significant congenital heart disease
• Surgeon/anaesthetist discretion

Indications for continuous monitored overnight oximetry on Campbell Ward:

• Older child (>2 yrs) with history suggestive of OSA
• Mild OSA (RDI <25) proven on sleep study
• Recent/current URTI

Other Patients: Admit overnight to a ward used to caring for post- tonsillectomy patients for observations of conscious state/bleeding/vomiting/fluid balance/analgesia requirements etc.

Post-Tonsillectomy Analgesia:

• Usually paracetamol only (hence value of opioid in theatre)
• If analgesic requirements greater, should be reviewed by surgeon

 References:

• Rosen, G; Muckle, R; Mahowald, M; Goding, G; Ullevig, C. Post-operative respiratory compromise in children with obstructive sleep apnoea syndrome: Can it be anticipated? Pediatrics. 1994; 93(5): 784-788.
• Biavati, M; Manning, S; Phillips, D. Predictive factors for respiratory complications after tonsillectomy and adenoidectomy in children. Archives of Otolaryngology head and neck surgery. 1997; 123:517-521.
• Helfaer, M; McColley, S; Pyzik, P; et al. Polysomnography after adenotonsillectomy in mild pediatric obstructive sleep apnoea. Critical Care Medicine. 1996; 24(8):1323-1327.
• Wilson, K; Lakheeram, I; Morielli, A; Broulillette, R; Brown K. Can assessment for obstructive sleep apnea help predict postadenotonsillectomy respiratory complications? Anesthesiology. 2002; 96: 313-322.

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