Tonsillectomy and Adenoidectomy (T&A)

Patient Considerations

• Indicated for

  • Sleep Disordered Breathing

  • Frequent Tonsillitis – 4 infections in 1 year or severe complications of strep

Associated Comorbidities/Syndromes

Case Planning

• Specific or Unique Room Set-Up Requirements

  • Airway – Intubate the patient

  • Drugs –

    • Dexamethasone 0.25-0.5mg/kg up to 12 mg

    • Narcotics

      • Fentanyl (1-2mcg/kg)

    • Morphine (usually given sparingly in PACU for patients with SDB)

  • Monitors – standard, EKG, O2 Sat, NIBP, skin temperature

  • Blood Availability – not routine

  • PICU Bed Availability – not routine

Anesthetic Considerations

• Induction – gentle mask induction

  • Be alert for airway obstruction especially in patients with enlarged adenoids and tonsils – they may require use of an oropharyngeal airway early

  • Establish IV access

  • Facilitate intubation with Propofol (2-4mg/kg)

  • Tape tube in midline – allows for use of the Crow-Davis gag for suspension by surgeon

    • Ensure entire ETT is midline before taping, if tube is off to the side of the pharynx but taped midline, the patient may accidentally be extubated when the retractor is placed

• Positioning

  • Bed is turned 90 degrees for the procedure

• Maintenance

  • Maintenance of Anesthesia

    • Inhalation

      • Establish return of spontaneous ventilation as soon as possible, titrate narcotics to respiratory rate

      • Reduce FiO2 to less than 30% - surgeon will use the electrocautery in this procedure so there is increased risk of an airway fire

        • Dr. Borders uses a cobalator which has less airway fire risk.

      • Give decadron early in the case

      • Use ondansetron in patients greater than 3 years of age

    • Hemodynamic/Physiologic goals

      • Systolic BP within 10-15% of baseline

      • Replace at least 50% of fluid deficit

      • Monitor blood loss – usually low if electrocautery used

      • Watch for kinking of ETT in Crowe-Davis gag when suspending patient

Emergence/Disposition

• Patients with frequent tonsillitis – may either wake up or extubate deep

  • If deep - patient on 100% FiO2

  • Gently suction oral pharynx

  • MAC of 1.6 to 2

  • Place oropharyngeal airway after extubation

  • Transport patient in the recovery position – left lateral – with FM O2

• Patients with Sleep Disordered Breathing/ OSA – wake up in OR attempting to avoid coughing.

  • Be prepared to give narcotics and or Precedex after extubation to calm patient prior to transport to PACU

• Kids under age 3 or with severe OSA are routinely observed overnight on the floor

Post-Op Pain Management

• Plan for a long acting narcotic, titrated to effect

  • Beware of OSA patients who may be very susceptible to narcotics

  • If patient is an out-patient, check to see if the surgeon’s prescription contains acetaminophen – if so do not administer acetaminophen in PACU

• Many surgeons use local at the site of surgery

  • May impact the patient’s ability to protect their airway

Case-Specific Complications

• These patients are at great risk for both laryngospasm and bronchospasm – be wary!!