Anesthesia For Tonsilectomy
Anesthesia For Tonsilectomy
Anesthesia For Tonsilectomy
Young age
Medical co-morbidity.
Preoperative assessment and premedication
Fitness for anaesthesia should be assessed on a case-by- case basis. Generally, a child
with clear nasal secretions who is systemically well, with no associated fever or chest
signs, is considered to be fit for anaesthesia. A cough is a sign of increased airway
irritability, and portends an elevated risk of airway complications, such as breath-
holding, laryngospasm and desaturation.
The gold standard for securing a childs airway is a tracheal tube. A preformed south-
facing tube is preferable. A large number of tonsillectomies have been undertaken
with a laryngeal mask airway (LMA). However, there is a learning curve associated
with the use of LMA in tonsillectomies, and it is usual to use a reinforced LMA.
When the Boyle Davis mouth gag is inserted, it is crucial that the airway remains
unobstructed, and that the endotracheal tube is still correctly positioned.
Perioperative analgesia
Recommendations
Local anaesthetic injection in the tonsillar fossa may improve pain scores, reduce time
to first oral intake, and reduce the incidence of referred ear pain following
tonsillectomy.
The use of NSAIDS in adenotonsillectomy has been the subject of ongoing debate. A
Cochrane review of this issue concluded that there is no evidence that NSAIDs, with
the exception of ketorolac, cause bleeding that increases the need to return to theatre,
and that moreover, postoperative nausea and vomiting is reduced when NSAIDs are
used. Post-tonsillectomy haemorrhage rates with ketorolac range from 4.4-18%.
Therefore, the use of ketorolac should be avoided.
Prevention of postoperative nausea and vomiting
The anaesthetic management of these cases is challenging, and can be fraught with
hazards. Children undergoing emergency surgery for post-tonsillectomy haemorrhage
represent a unique group of patients at risk of life-threatening complications which
can be minimised with proper preparation for airway management and blood-volume
resuscitation.
The main factors to consider are: The child may be hypovolaemic. The stomach may
be full of swallowed blood. Repeat anaesthetic. A potentially difficult airway.
Circulatory compensation is remarkable until about 40% of the blood volume has
been lost, and hypovolaemia is thus often masked. Signs that should be looked for are
increased swallowing, pallor, and an unexplained tachycardia. A full blood count,
clotting screen and cross-match should be taken, and the child adequately resuscitated
prior to commencement of anaesthesia.
The pre-operative visit should also exclude evidence of active infection, check for
loose teeth and consent for perioperative analgesia.