Paediatric tonsillectomy

 

Pre-op issues:

Induction distress

Problems:

·     Fear

·     Separation anxiety

·     Pre-med: unsafe if OSA

·     IV: don’t like needles, risk of missed attempt

·     Inhalation: don’t like mask, risk of airway complications

Prevention:

·     Parent: in the room until LOC

·     Topicalise: amethocaine cream

·     Pre-med: ok if line of sight nursing

·     IV: if amenable child and good vein

·     Inhalation: need IM sux drawn up

 

Intra-op issues:

CICO

Problems:

·     ±Large tonsils

·     ±Obesity

·     ±Abnormal upper airway anatomy

Solution:

·     Plan ABCD

·     ±Second anaesthetist

C-spine injury

Problem:

·     Extreme neck extension

Solution:

·     Discuss with surgeon

·     ±C-spine X ray with flexion and extension views

·     ±Modified positioning

Laryngospasm

Causes:

·     Inadequate anaesthesia

·     Airway manipulation

·     Painful stimulation

Prevention:

·     Induction: CPAP + avoid manipulation during excitement

·     Incision: 1 MAC sevoflurane + fentanyl 1mcg/kg 5 mins prior

·     Extubation: ppF 3mg/kg + suction + deflate + extubate + CPAP

Aspiration

Problem:

·     Soiled, bloody airway

·     Deep extubation

Prevention:

·     Suction pharynx and nasopharynx (‘coroner’s clot’)

·     Ensure haemostasis before extubation

·     Lateral decubitus at extubation

 

Post-op issues:

Pain

Conflict:

·     Very painful

·     At risk of obtundation

Compromise:

·     Local anaesthetic by surgeon

·     Maximise non-opioids: paracetamol, COX2i, clonidine, (tramadol)

·     Evaluate opioid sensitivity intra-op: fentanyl 1mcg/kg q5 min

·     Low dose opioid for ward: oxycodone 0.1mg/kg Q3H PRN

·     Trial oral opioid in PACU

Nausea

Problems:

·     Volatile anaesthetic

·     Opioid

·     Blood in stomach

Prevention:

·     Switch to propofol TIVA mid-procedure

·     Multiple anti-emetics intra-op

·     Ensure haemostasis before extubation

·     Decompress stomach if bleeding +++

Emergence delirium

Problems:

·     Pre-school age

·     Anxiety

·     Volatile anaesthetic

·     Surgery

·     Pain

Prevention:

·     Midazolam pre-med if safe

·     Switch to propofol TIVA before emergence

·     Clonidine 1mcg/kg

·     Oxycodone 0.2mg/kg intra-op

Obstruction

Problem:

·     Swollen airway

·     Opioid analgesia

·     ±OSA

Risk factors:

·     Severe OSA
Or mild-mod plus:

·     Morbidly obese

·     Very young (<3)

·     Major comorbidity (heart, lung, neuromuscular)

·     Abnormal upper airway anatomy

Prevention:

·     Extubate left lateral + deep + wait in theatre until safe

·     Admit overnight if any OSA

·     HDU if severe OSA or any OSA + risk factor

·     Multi-modal analgesia

 

 

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