Tonsillectomy +- adenoidectomy
Clinical Procedure
 
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Ts & As
T & A
T&A
Ts and As

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Indications and coomorbidities in paediatric tonsillectomy is evolving.
#spanza2012 #CO

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Nov 24, 2012
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Determine whether patient has been diagnosed with, or has symptoms consistent with OSA.
This both determines suitability for proceeding as a day case and whether the patient may be at elevated risk of opioid induced respiratory depression that may require overnight monitoring or reduced dose opioids.

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Jul 29, 2012
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If day case, & want to spontaneously ventilate after relaxant induction, use short acting NDMR rather than suxamethonium as the myalgia it can cause can delay discharge

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Jul 09, 2011
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Oral RAE endotracheal tube

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May 18, 2011
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Positive pressure ventilation may help keep blood out of the trachea. Pressure support ventilation mode, with backup alarms, can be useful to monitor for obstruction of the tracheal tube

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Jul 09, 2011
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Shared airway. ETT can be inadvertantly withdrawn or compressed by surgeon

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Jul 09, 2011
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Suction prior to extubation. Under direct laryngoscopy whilst deep, to remove residual clot. Lift head up to shake clot from nasopharynx

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May 18, 2011
You may be comfortable with the surgeon performing this before removal of Boyle-Davis gag. You still the own airway risks & consequences.
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The visual feedback of a reseviour bag in a spontaneously venting patient to monitor ETT patency may be useful in picking up occlusion of the endotracheal tube

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Jul 18, 2012
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2.5 mcg/kg of fentanyl is sufficient to prevent emergence agitation in adenoidectomy when desflurane is used refl.in/4q

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Jul 29, 2012
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ADULT: NSAIDS increased risk of reoperation. Marret et al Anesthesiology 2003;98:1497-1502 refl.in/z

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May 18, 2011
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Cochrane review showed no increase in periop tonsillar bleeding in children given NSAIDS. refl.in/y

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Jul 09, 2011
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Dexamethasone intraoperatively reduces postoperative pain #ref

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Aug 02, 2011
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High risk for post operative nausea (PONV) refl.in/5

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May 18, 2011
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Moderate operative pain, opiods usually required.

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Fentanyl more titrateable than morphine.
0.5mcg/kg Fentanyl at beginning of case
Titrate to pain/breathing (eg to total 1-2mcg/kg) throughout case. (#NR)
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Surgeon may want to avoid non-steroidal anti-inflammatories (NSAIDS) due their concern of a theoretical bleeding risk

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Cochrane review showed no increase in periop tonsillar bleeding in children on NSAIDS. refl.in/y
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Avoid coughing and straining on emergence to reduce perioperative bleeding

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May 18, 2011
Extubate kids deep, in the lateral position, if you feel confident that they are easy to mask ventilate, otherwise extubate awake when upper airway reflexes have returned.
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Patients with obstructive sleep apnoea generally aren't suitable for day case surgery. At increased risk of opiod respiratory depression.

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May 18, 2011
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Paediatric tonsillectomy:
Gas induction,
insert IV when deep,
LA to chords,
fentanil 2mcg/kg IV,
wait for HR to decrease & intubate.
Manually ventilate during case.
Extubate deep in lateral position with guedel airway

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Jul 05, 2013
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