What are some of the complications of tonsillar hyperplasia?
- Chronic airway obstruction— sleep apnea
- C02 retention
- Intermittent nocturnal hypoxemia
- Cor pulmonale
- Failure to thrive
- Swallowing disorders
- Speech abnormalities
In the anesthetic management of a tonsillectomy, what dictates pain management?
- Surgical technique:
- Hot knife (less pain, increased bleeding)
- Unipolar
- Bipolar
- BLEEDING BURNS AND AIRWAY FIRES ACCOUNT FOR 1/3 OF MALPRACTICE CLAIMS
What are the most common surgical complications of tonsillectomy?
- Majority of children <3 years old experience airway problems
- Hemorrhage most common after 10 years old
What are the most important parts in the pre-op for a tonsillectomy?
- History of bleeding tendencies
- Patient on ASA, NSAIDs, and Valproic acid
- DISTINGUISH OSA FROM OBSTRUCTION
AFRICAN-AMERICAN CHILDREN DESATURATE MORE PROFOUNDLY - CBC
- Chronic tonsillar hypertrophy may cause hypoxemia and hypercarbia— cor pulmonale
- Loud snoring? Respiratory pauses? Tired? Poor school performance? ADD? Weight greater than 95%
What are the most important aspects of emergence in the patient undergoing a tonsillectomy?
- Rapid emergence so the child is awake and protecting airway
- DECREASED INCIDENCE OF REACTIVE AIRWAY AND LARYNGOSPASM
- LEAK AT 20cm, INCREASES WITH NECK EXTENSION AND INSERTION ON MOUTH GAG
- CUFF TUBE BECOMING MORE COMMON
What are the advantages of a cuffed tube in the anesthetic management of tonsillectomy?
- Minimizes WAG pollution
- DECREASES RISK OF AIRWAY FIRE
When airway and pharyngeal reflexes are protected on emergence, what are we avoiding?
- Aspiration
- Laryngospasm
- Airway obstruction
- OGT before extubation (suction blood and secretions)
What are the most important aspects of emerging the patient undergoing a tonsillectomy?
- CHILD SHOULD BE FULLY AWAKE
- LATERAL TONSILLAR POSITION (HEAD SLIGHTLY DOWN AT TIME OF EXTUBATION, BLOOD AND SECRETIONS POOL IN CHEEK AND DRAINS MOUTH AWAY FROM LARYNGEAL INLET)
What are the advantages of LMA vs. ETT for tonsillectomy?
- Decreased post-p stridor
- Decreased laryngospasm
- Increased immediate post-op oxygenation
- Risk for airway fire if leak around LMA
What are important consideration when treating pain during tonsillectomies?
- Electrocautery causes more pain
- Decadron
- NSAIDS- CONSULT W/ SURGEON AFTER HEMOSTASIS ACHIEVED
- OFIRMEV CATASTROPHIC W/ INFANTS
What does evidence suggest improves PONV and morbidity after adenotonsillectomy?
- GIVE DECADRON, IMPROVED OUTCOMES
- Propofol gtt reduces PONV
- Zofran
What are possible complications in the pain treatment ofthe patient undergoing tonsillectomy?
- LOCAL INFILTRATION OF LOCAL ANESTHETIC, USE NEURAL MUSCULAR BLOCKADE
- MAY CAUSE SEVERE UPPER AIRWAY OBSTRUCTION, PULMONARY EDEMA
- Pharynx in children w/ OSA are more collapsible
What are the most important considerations in post-tonsillectomy bleeding?
- Bleeding can occur 24 hrs days after or 5-10 days post-surgery
If a patient has orthostatic hypotension secondary to post-op hemorrhage after a tonsillectomy how should fluid resuscitation be managed?
- IF 20% OF CIRCULATING BLOOD VOLUME IS LOST: (AGGRESSIVE FLUID RESUSCITATION, CROSS/MATCH BLOOD)
- IF PATIENT IS NOT HYPOTENSIVE: (will be hypovolemic, decreased C02 secondary to blood loss and hypoperfusion)
Describe induction for a bleeding tonsillectomy
- Preoxygenate in the left lateral position w/ head down to drain blood
- Intubated supine and under RSI
- Cuffed ETT
- OGT for suction, may not be able to empty stomach due to bleeding being clotted
- ZOFRAN
