Tonsillectomy and/or adenoidectomy - Revision history

Tony.Wang at 11:33, 12 June 2024

2024-06-12T11:33:15Z

← Older revision		Revision as of 04:33, 12 June 2024
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	*Intubation with cuffed ETT - consider oral RAE or wire-reinforced ETT		*Intubation with cuffed ETT - consider oral RAE or wire-reinforced ETT
	**If in-between sizes for oral RAE, consider larger size given the risk of extubating with neck extension during surgery<ref>{{Cite journal\|last=Wynne\|first=D.M.\|last2=Marshall\|first2=J.N.\|date=2002-10-01\|title=Risk of accidental extubation with disposable tonsillectomy instruments\|url=https://doi.org/10.1093/bja/aef548\|journal=British Journal of Anaesthesia\|volume=89\|issue=4\|pages=659\|doi=10.1093/bja/aef548\|issn=0007-0912\|via=}}</ref>		**If in-between sizes for oral RAE, consider larger size given the risk of extubating with neck extension during surgery<ref>{{Cite journal\|last=Wynne\|first=D.M.\|last2=Marshall\|first2=J.N.\|date=2002-10-01\|title=Risk of accidental extubation with disposable tonsillectomy instruments\|url=https://doi.org/10.1093/bja/aef548\|journal=British Journal of Anaesthesia\|volume=89\|issue=4\|pages=659\|doi=10.1093/bja/aef548\|issn=0007-0912\|via=}}</ref>
			**If normal ETT, tape midline
	*Deep intubation vs paralysis		*Deep intubation vs paralysis
	**T&As are generally short procedures (30 min - 1 hour)		**T&As are generally short procedures (30 min - 1 hour)

CFitzgerald: post-op complications and planning, otherwise minor edits

2022-07-20T20:19:52Z

post-op complications and planning, otherwise minor edits

Show changes

Tony.Wang at 18:13, 26 April 2022

2022-04-26T18:13:01Z

← Older revision		Revision as of 11:13, 26 April 2022
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	===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===		===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===

			*Procedure itself is quite painful
	*Multimodal pain control is strongly preferred, given that children with OSA are more susceptible to the respiratory depressant effects of opioids		*Multimodal pain control is strongly preferred, given that children with OSA are more susceptible to the respiratory depressant effects of opioids
	**Nonopioids		**Nonopioids

Tony.Wang: added dexamethasone

2022-04-26T17:57:14Z

added dexamethasone

← Older revision		Revision as of 10:57, 26 April 2022
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	*Lower FiO2 to lowest possible to reduce risk of airway fire		*Lower FiO2 to lowest possible to reduce risk of airway fire
	*Consider higher volume hydration (if tolerated) to prevent PONV		*Consider higher volume hydration (if tolerated) to prevent PONV
			*Consider dexamethasone 0.5 mg/kg IV to prevent airway edema

	===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===		===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===

Chris.Rishel at 07:50, 5 April 2022

2022-04-05T07:50:51Z

← Older revision		Revision as of 00:50, 5 April 2022
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	{{Infobox surgical case reference		{{Infobox surgical case reference
	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = ETT, consider oral RAE		\| airway = ETT (consider oral RAE)
	\| lines_access = PIV		\| lines_access = PIV
	\| monitors = Standard ~~ASA monitors~~		\| monitors = Standard
	5-lead ~~EKG if needed~~		5-lead ECG
	\| considerations_preoperative = Assess OSA severity if present		\| considerations_preoperative = Assess OSA severity if present
	~~Consider distraction methods instead of~~ anxiolytics if severe OSA		Avoid anxiolytics if severe OSA
	\| considerations_intraoperative = Mask induction if no PIV		\| considerations_intraoperative = Mask induction if no PIV
	Shared airway with surgeon		Shared airway with surgeon
	Lower ~~FiO2~~ to reduce risk of airway fire		Lower FiO<sub>2</sub> to reduce risk of airway fire
	Emerge after complete hemostasis is achieved		Emerge after complete hemostasis is achieved
	Protect airway from blood/secretions		Protect airway from blood/secretions

Chris.Rishel at 06:13, 22 February 2022

2022-02-22T06:13:11Z

← Older revision		Revision as of 23:13, 21 February 2022
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	'''Tonsillectomy and/or adenoidectomy''' (often abbreviated '''T&A''') is a surgical procedure to remove the tonsils with/without adenoids, which are lymphoid tissues encircling the posterior oropharynx.{{Infobox surgical case reference		{{Infobox surgical case reference
	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = ETT, consider oral RAE		\| airway = ETT, consider oral RAE
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	PONV prophylaxis		PONV prophylaxis
	}}		}}
			'''Tonsillectomy and/or adenoidectomy''' (often abbreviated '''T&A''') is a surgical procedure to remove the tonsils with/without adenoids, which are lymphoid tissues encircling the posterior oropharynx. Indications for T&As include 1) recurrent throat infections, 2) obstructive sleep-disordered breathing<ref name=":0">{{Cite journal\|last=Mitchell\|first=Ron B.\|last2=Archer\|first2=Sanford M.\|last3=Ishman\|first3=Stacey L.\|last4=Rosenfeld\|first4=Richard M.\|last5=Coles\|first5=Sarah\|last6=Finestone\|first6=Sandra A.\|last7=Friedman\|first7=Norman R.\|last8=Giordano\|first8=Terri\|last9=Hildrew\|first9=Douglas M.\|last10=Kim\|first10=Tae W.\|last11=Lloyd\|first11=Robin M.\|date=2019-02-01\|title=Clinical Practice Guideline: Tonsillectomy in Children (Update)\|url=https://doi.org/10.1177/0194599818801757\|journal=Otolaryngology–Head and Neck Surgery\|language=en\|volume=160\|issue=1_suppl\|pages=S1–S42\|doi=10.1177/0194599818801757\|issn=0194-5998}}</ref>. While infections used to be the most common indication in the past, the majority of tonsillectomies are now being performed for obstructive sleep apnea (OSA). Tonsillectomies are the second most common ambulatory surgery performed in children under 15 years old in the United States<ref>{{Cite web\|title=Ambulatory surgery in the United States, 2006\|url=https://stacks.cdc.gov/view/cdc/5395\|access-date=2021-05-16\|website=stacks.cdc.gov}}</ref>.
	Indications for T&As include 1) recurrent throat infections, 2) obstructive sleep-disordered breathing<ref name=":0">{{Cite journal\|last=Mitchell\|first=Ron B.\|last2=Archer\|first2=Sanford M.\|last3=Ishman\|first3=Stacey L.\|last4=Rosenfeld\|first4=Richard M.\|last5=Coles\|first5=Sarah\|last6=Finestone\|first6=Sandra A.\|last7=Friedman\|first7=Norman R.\|last8=Giordano\|first8=Terri\|last9=Hildrew\|first9=Douglas M.\|last10=Kim\|first10=Tae W.\|last11=Lloyd\|first11=Robin M.\|date=2019-02-01\|title=Clinical Practice Guideline: Tonsillectomy in Children (Update)\|url=https://doi.org/10.1177/0194599818801757\|journal=Otolaryngology–Head and Neck Surgery\|language=en\|volume=160\|issue=1_suppl\|pages=S1–S42\|doi=10.1177/0194599818801757\|issn=0194-5998}}</ref>. While infections used to be the most common indication in the past, the majority of tonsillectomies are now being performed for obstructive sleep apnea (OSA). Tonsillectomies are the second most common ambulatory surgery performed in children under 15 years old in the United States<ref>{{Cite web\|title=Ambulatory surgery in the United States, 2006\|url=https://stacks.cdc.gov/view/cdc/5395\|access-date=2021-05-16\|website=stacks.cdc.gov}}</ref>.

	== Preoperative management==		== Preoperative management==
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	!System		!System
	!Considerations		!Considerations
			\|-
			\|Airway
			\|
	\|-		\|-
	\|Neurologic		\|Neurologic

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:43:12Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:43, 21 February 2022
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	\|		\|
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|		\|
	* OSA is the most common indication for T&As. Polysomnography (sleep study) is useful to assess for severity of OSA. For patients without a polysomnography, ask about snoring and apnea; other symptoms may include excessive daytime sleepiness, inattention, poor concentration, or hyperactivity.		* OSA is the most common indication for T&As. Polysomnography (sleep study) is useful to assess for severity of OSA. For patients without a polysomnography, ask about snoring and apnea; other symptoms may include excessive daytime sleepiness, inattention, poor concentration, or hyperactivity.

Chris.Rishel at 21:14, 21 February 2022

2022-02-21T21:14:36Z

← Older revision		Revision as of 14:14, 21 February 2022
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	<references />		<references />
			[[Category:Otolaryngology]]
			[[Category:Pharyngeal surgery]]

Annie Tran at 03:21, 13 September 2021

2021-09-13T03:21:12Z

Annie Tran at 03:16, 13 September 2021

2021-09-13T03:16:19Z

← Older revision		Revision as of 20:16, 12 September 2021
Line 13:		Line 13:
	Protect airway from blood/secretions		Protect airway from blood/secretions
	Increased incidence of laryngospasm		Increased incidence of laryngospasm
	\| considerations_postoperative = High risk of postoperative respiratory complications		\| considerations_postoperative = Smooth, rapid emergence (short case)
			High risk of postoperative respiratory complications
	OSA precautions		OSA precautions
	PONV prophylaxis		PONV prophylaxis
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	\|Gastrointestinal		\|Gastrointestinal
	\|		\|
			* Standard NPO guidelines.
	\|-		\|-
	\|Hematologic		\|Hematologic
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	*Consider <u>distraction methods</u> (toys, videos, tablet computers, games, parental presence if deemed appropriate) as opposed to anxiolytics in children with severe OSA		*Consider <u>distraction methods</u> (toys, videos, tablet computers, games, parental presence if deemed appropriate) as opposed to anxiolytics in children with severe OSA
	*If giving preoperative <u>anxiolytics</u>, consider <u>continuous pulse oximetry monitoring</u> for children with OSA		*If giving preoperative <u>anxiolytics</u>, consider <u>continuous pulse oximetry monitoring</u> for children with OSA<ref>{{Cite journal\|last=Van Someren\|first=V. H.\|last2=Hibbert\|first2=J.\|last3=Stothers\|first3=J. K.\|last4=Kyme\|first4=M. C.\|last5=Morrison\|first5=G. A.\|date=1990-06\|title=Identification of hypoxaemia in children having tonsillectomy and adenoidectomy\|url=https://pubmed.ncbi.nlm.nih.gov/2394027\|journal=Clinical Otolaryngology and Allied Sciences\|volume=15\|issue=3\|pages=263–271\|doi=10.1111/j.1365-2273.1990.tb00784.x\|issn=0307-7772\|pmid=2394027}}</ref>
	*Consider preoperative <u>albuterol</u> treatment for patients with recent URI <2 weeks ago or moderate-severe OSA		*Consider preoperative <u>albuterol</u> treatment for patients with recent URI <2 weeks ago or moderate-severe OSA

	===Regional and neuraxial techniques<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===		===Regional and neuraxial techniques<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===

	*<u>Local anesthesia</u> is controversial and not preferred (risk of significant complications associated with local infiltration)		*<u>Local anesthesia</u> is controversial and not preferred (risk of significant complications associated with local infiltration)<ref>{{Cite journal\|last=Hollis\|first=L. J.\|last2=Burton\|first2=M. J.\|last3=Millar\|first3=J. M.\|date=2000\|title=Perioperative local anaesthesia for reducing pain following tonsillectomy\|url=https://pubmed.ncbi.nlm.nih.gov/10796831\|journal=The Cochrane Database of Systematic Reviews\|issue=2\|pages=CD001874\|doi=10.1002/14651858.CD001874\|issn=1469-493X\|pmc=7025437\|pmid=10796831}}</ref><ref>{{Cite journal\|last=Bean-Lijewski\|first=J. D.\|date=1997-06\|title=Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial\|url=https://pubmed.ncbi.nlm.nih.gov/9174298\|journal=Anesthesia and Analgesia\|volume=84\|issue=6\|pages=1232–1238\|doi=10.1097/00000539-199706000-00011\|issn=0003-2999\|pmid=9174298}}</ref>

	==Intraoperative management==		==Intraoperative management==
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	*Mask induction if no PIV		*Mask induction if no PIV
	*Intubation with cuffed ETT - consider oral RAE or wire-reinforced ETT		*Intubation with cuffed ETT - consider oral RAE or wire-reinforced ETT
	**If in-between sizes for oral RAE, consider larger size given the risk of extubation with neck extension during surgery		**If in-between sizes for oral RAE, consider larger size given the risk of extubation with neck extension during surgery<ref>{{Cite journal\|last=Wynne\|first=D.M.\|last2=Marshall\|first2=J.N.\|date=2002-10\|title=Risk of accidental extubation with disposable tonsillectomy instruments\|url=https://doi.org/10.1093/bja/aef548\|journal=British Journal of Anaesthesia\|volume=89\|issue=4\|pages=659\|doi=10.1093/bja/aef548\|issn=0007-0912}}</ref>
	*Deep intubation vs paralysis		*Deep intubation vs paralysis
	**T&As are generally short procedures (30 min - 1 hour)		**T&As are generally short procedures (30 min - 1 hour)
Line 97:		Line 99:

	*Supine with neck extended		*Supine with neck extended
	**Increased risk of accidental extubation with neck extension
	*Table is usually turned 90 degrees		*Table is usually turned 90 degrees

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	*Consider arranging for overnight, inpatient postoperative monitoring for:		*Consider arranging for overnight, inpatient postoperative monitoring for:
	*#Patients <3 years old, or		*#Patients <3 years old, or
	*#Patients with severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both)<ref name=":0" />.		*#Patients with severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both)<ref name=":0" /><ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912}}</ref>.

	===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===		===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===
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	*Multimodal pain control is strongly preferred, given that children with OSA are more susceptible to the respiratory depressant effects of opioids		*Multimodal pain control is strongly preferred, given that children with OSA are more susceptible to the respiratory depressant effects of opioids
	**Nonopioids		**Nonopioids
	***~~Decadron~~		***IV dexamethasone (usually 0.1 to 0.5 mg/kg IV, maximum of 4 mg)
	***IV acetaminophen (usually 15mg/kg for patients above age 2, 10mg/kg for children below 2 years old)		***IV acetaminophen (usually 15mg/kg for patients above age 2, 10mg/kg for children below 2 years old)
	***Dexmedetomidine		***Dexmedetomidine (single dose 0.5 mcg/kg)<ref>{{Cite journal\|last=Guler\|first=Gulen\|last2=Akin\|first2=Aynur\|last3=Tosun\|first3=Zeynep\|last4=Ors\|first4=Sevgi\|last5=Esmaoglu\|first5=Aliye\|last6=Boyaci\|first6=Adem\|date=2005-09\|title=Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy\|url=https://pubmed.ncbi.nlm.nih.gov/16101707/\|journal=Paediatric Anaesthesia\|volume=15\|issue=9\|pages=762–766\|doi=10.1111/j.1460-9592.2004.01541.x\|issn=1155-5645\|pmid=16101707}}</ref>
			***Consider low-dose ketamine as an opioid-sparing agent in patients with severe OSA; however it may also increase postoperative agitation and secretions
	***IV NSAIDs are controversial because of the risk of tonsillar bleeding		***IV NSAIDs are controversial because of the risk of tonsillar bleeding
	***Consider low-dose ketamine as an opioid-sparing agent in patients with severe OSA; however it may also increase postoperative agitation and secretions
	**Opioids		**Opioids
	***Consider reducing opioid doses by 50% for children with OSA		***Consider reducing opioid doses by 50% for children with significant OSA, accompanied by continuous monitoring including pulse oximetry<ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912}}</ref>

			=== PONV prophylaxis ===

			* Serotonergic antagonists
			** Ondansetron (0.1 mg/kg single dose; maximum 4 mg) with intraoperative dexamethasone<ref>{{Cite journal\|last=Bolton\|first=C. M.\|last2=Myles\|first2=P. S.\|last3=Nolan\|first3=T.\|last4=Sterne\|first4=J. A.\|date=2006-11\|title=Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis\|url=https://pubmed.ncbi.nlm.nih.gov/17005507\|journal=British Journal of Anaesthesia\|volume=97\|issue=5\|pages=593–604\|doi=10.1093/bja/ael256\|issn=0007-0912\|pmid=17005507}}</ref>
			* Promethazine is associated with risk of sedation and respiratory depression in the setting of residual anesthesia and opioids <ref>{{Cite journal\|last=Starke\|first=Peter R.\|last2=Weaver\|first2=Joyce\|last3=Chowdhury\|first3=Badrul A.\|date=2005-06-23\|title=Boxed warning added to promethazine labeling for pediatric use\|url=https://pubmed.ncbi.nlm.nih.gov/15972879\|journal=The New England Journal of Medicine\|volume=352\|issue=25\|pages=2653\|doi=10.1056/NEJM200506233522522\|issn=1533-4406\|pmid=15972879}}</ref>

	===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===		===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===

	*High risk of postoperative pulmonary complications		*High risk of '''postoperative pulmonary complications''', especially in patients with severe OSA<ref>{{Cite web\|last=Marrugo Pardo\|first=G.\|last2=Romero Moreno\|first2=L. F.\|last3=Beltrán Erazo\|first3=P.\|last4=Villalobos Aguirre\|first4=C.\|date=2018-11-01\|title=Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population\|url=https://www.hindawi.com/journals/sd/2018/1968985/\|access-date=2021-09-13\|website=Sleep Disorders\|language=en}}</ref><ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912}}</ref>
	*Risk of postoperative hemorrhage		*Risk of '''postoperative hemorrhage''' and its associated adverse events, including hypoxemia (most common adverse event), bradycardia, hypotension, and difficult intubation<ref>{{Cite journal\|last=Fields\|first=Ryan G.\|last2=Gencorelli\|first2=Frank J.\|last3=Litman\|first3=Ronald S.\|date=2010-11\|title=Anesthetic management of the pediatric bleeding tonsil\|url=https://pubmed.ncbi.nlm.nih.gov/20964765\|journal=Paediatric Anaesthesia\|volume=20\|issue=11\|pages=982–986\|doi=10.1111/j.1460-9592.2010.03426.x\|issn=1460-9592\|pmid=20964765}}</ref>

	==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==		==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==

← Older revision		Revision as of 20:21, 12 September 2021
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	*Consider <u>distraction methods</u> (toys, videos, tablet computers, games, parental presence if deemed appropriate) as opposed to anxiolytics in children with severe OSA		*Consider <u>distraction methods</u> (toys, videos, tablet computers, games, parental presence if deemed appropriate) as opposed to anxiolytics in children with severe OSA
	*If giving preoperative <u>anxiolytics</u>, consider <u>continuous pulse oximetry monitoring</u> for children with OSA<ref>{{Cite journal\|last=Van Someren\|first=V. H.\|last2=Hibbert\|first2=J.\|last3=Stothers\|first3=J. K.\|last4=Kyme\|first4=M. C.\|last5=Morrison\|first5=G. A.\|date=1990-06\|title=Identification of hypoxaemia in children having tonsillectomy and adenoidectomy\|url=https://pubmed.ncbi.nlm.nih.gov/2394027\|journal=Clinical Otolaryngology and Allied Sciences\|volume=15\|issue=3\|pages=263–271\|doi=10.1111/j.1365-2273.1990.tb00784.x\|issn=0307-7772\|pmid=2394027}}</ref>		*If giving preoperative <u>anxiolytics</u>, consider <u>continuous pulse oximetry monitoring</u> for children with OSA<ref>{{Cite journal\|last=Van Someren\|first=V. H.\|last2=Hibbert\|first2=J.\|last3=Stothers\|first3=J. K.\|last4=Kyme\|first4=M. C.\|last5=Morrison\|first5=G. A.\|date=1990-06-01\|title=Identification of hypoxaemia in children having tonsillectomy and adenoidectomy\|url=https://pubmed.ncbi.nlm.nih.gov/2394027\|journal=Clinical Otolaryngology and Allied Sciences\|volume=15\|issue=3\|pages=263–271\|doi=10.1111/j.1365-2273.1990.tb00784.x\|issn=0307-7772\|pmid=2394027\|via=}}</ref>
	*Consider preoperative <u>albuterol</u> treatment for patients with recent URI <2 weeks ago or moderate-severe OSA		*Consider preoperative <u>albuterol</u> treatment for patients with recent URI <2 weeks ago or moderate-severe OSA

	===Regional and neuraxial techniques<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===		===Regional and neuraxial techniques<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->===

	*<u>Local anesthesia</u> is controversial and not preferred (risk of significant complications associated with local infiltration)<ref>{{Cite journal\|last=Hollis\|first=L. J.\|last2=Burton\|first2=M. J.\|last3=Millar\|first3=J. M.\|date=2000\|title=Perioperative local anaesthesia for reducing pain following tonsillectomy\|url=https://pubmed.ncbi.nlm.nih.gov/10796831\|journal=The Cochrane Database of Systematic Reviews\|issue=2\|pages=CD001874\|doi=10.1002/14651858.CD001874\|issn=1469-493X\|pmc=7025437\|pmid=10796831}}</ref><ref>{{Cite journal\|last=Bean-Lijewski\|first=J. D.\|date=1997-06\|title=Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial\|url=https://pubmed.ncbi.nlm.nih.gov/9174298\|journal=Anesthesia and Analgesia\|volume=84\|issue=6\|pages=1232–1238\|doi=10.1097/00000539-199706000-00011\|issn=0003-2999\|pmid=9174298}}</ref>		*<u>Local anesthesia</u> is controversial and not preferred (risk of significant complications associated with local infiltration)<ref>{{Cite journal\|last=Hollis\|first=L. J.\|last2=Burton\|first2=M. J.\|last3=Millar\|first3=J. M.\|date=2000\|title=Perioperative local anaesthesia for reducing pain following tonsillectomy\|url=https://pubmed.ncbi.nlm.nih.gov/10796831\|journal=The Cochrane Database of Systematic Reviews\|issue=2\|pages=CD001874\|doi=10.1002/14651858.CD001874\|issn=1469-493X\|pmc=7025437\|pmid=10796831}}</ref><ref>{{Cite journal\|last=Bean-Lijewski\|first=J. D.\|date=1997-06-01\|title=Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial\|url=https://pubmed.ncbi.nlm.nih.gov/9174298\|journal=Anesthesia and Analgesia\|volume=84\|issue=6\|pages=1232–1238\|doi=10.1097/00000539-199706000-00011\|issn=0003-2999\|pmid=9174298\|via=}}</ref>

	==Intraoperative management==		==Intraoperative management==
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	*Mask induction if no PIV		*Mask induction if no PIV
	*Intubation with cuffed ETT - consider oral RAE or wire-reinforced ETT		*Intubation with cuffed ETT - consider oral RAE or wire-reinforced ETT
	**If in-between sizes for oral RAE, consider larger size given the risk of extubation with neck extension during surgery<ref>{{Cite journal\|last=Wynne\|first=D.M.\|last2=Marshall\|first2=J.N.\|date=2002-10\|title=Risk of accidental extubation with disposable tonsillectomy instruments\|url=https://doi.org/10.1093/bja/aef548\|journal=British Journal of Anaesthesia\|volume=89\|issue=4\|pages=659\|doi=10.1093/bja/aef548\|issn=0007-0912}}</ref>		**If in-between sizes for oral RAE, consider larger size given the risk of extubation with neck extension during surgery<ref>{{Cite journal\|last=Wynne\|first=D.M.\|last2=Marshall\|first2=J.N.\|date=2002-10-01\|title=Risk of accidental extubation with disposable tonsillectomy instruments\|url=https://doi.org/10.1093/bja/aef548\|journal=British Journal of Anaesthesia\|volume=89\|issue=4\|pages=659\|doi=10.1093/bja/aef548\|issn=0007-0912\|via=}}</ref>
	*Deep intubation vs paralysis		*Deep intubation vs paralysis
	**T&As are generally short procedures (30 min - 1 hour)		**T&As are generally short procedures (30 min - 1 hour)
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	*Consider arranging for overnight, inpatient postoperative monitoring for:		*Consider arranging for overnight, inpatient postoperative monitoring for:
	*#Patients <3 years old, or		*#Patients <3 years old, or
	*#Patients with severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both)<ref name=":0" /><ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912}}</ref>.		*#Patients with severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both)<ref name=":0" /><ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12-01\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912\|via=}}</ref>.

	===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===		===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===
Line 130:		Line 130:
	***IV dexamethasone (usually 0.1 to 0.5 mg/kg IV, maximum of 4 mg)		***IV dexamethasone (usually 0.1 to 0.5 mg/kg IV, maximum of 4 mg)
	***IV acetaminophen (usually 15mg/kg for patients above age 2, 10mg/kg for children below 2 years old)		***IV acetaminophen (usually 15mg/kg for patients above age 2, 10mg/kg for children below 2 years old)
	***Dexmedetomidine (single dose 0.5 mcg/kg)<ref>{{Cite journal\|last=Guler\|first=Gulen\|last2=Akin\|first2=Aynur\|last3=Tosun\|first3=Zeynep\|last4=Ors\|first4=Sevgi\|last5=Esmaoglu\|first5=Aliye\|last6=Boyaci\|first6=Adem\|date=2005-09\|title=Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy\|url=https://pubmed.ncbi.nlm.nih.gov/16101707/\|journal=Paediatric Anaesthesia\|volume=15\|issue=9\|pages=762–766\|doi=10.1111/j.1460-9592.2004.01541.x\|issn=1155-5645\|pmid=16101707}}</ref>		***Dexmedetomidine (single dose 0.5 mcg/kg)<ref>{{Cite journal\|last=Guler\|first=Gulen\|last2=Akin\|first2=Aynur\|last3=Tosun\|first3=Zeynep\|last4=Ors\|first4=Sevgi\|last5=Esmaoglu\|first5=Aliye\|last6=Boyaci\|first6=Adem\|date=2005-09-01\|title=Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy\|url=https://pubmed.ncbi.nlm.nih.gov/16101707/\|journal=Paediatric Anaesthesia\|volume=15\|issue=9\|pages=762–766\|doi=10.1111/j.1460-9592.2004.01541.x\|issn=1155-5645\|pmid=16101707\|via=}}</ref>
	***Consider low-dose ketamine as an opioid-sparing agent in patients with severe OSA; however it may also increase postoperative agitation and secretions		***Consider low-dose ketamine as an opioid-sparing agent in patients with severe OSA; however it may also increase postoperative agitation and secretions
	***IV NSAIDs are controversial because of the risk of tonsillar bleeding		***IV NSAIDs are controversial because of the risk of tonsillar bleeding
	**Opioids		**Opioids
	***Consider reducing opioid doses by 50% for children with significant OSA, accompanied by continuous monitoring including pulse oximetry<ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912}}</ref>		***Consider reducing opioid doses by 50% for children with significant OSA, accompanied by continuous monitoring including pulse oximetry<ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12-01\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912\|via=}}</ref>

	=== PONV prophylaxis ===		=== PONV prophylaxis ===

	* Serotonergic antagonists		* Serotonergic antagonists
	** Ondansetron (0.1 mg/kg single dose; maximum 4 mg) with intraoperative dexamethasone<ref>{{Cite journal\|last=Bolton\|first=C. M.\|last2=Myles\|first2=P. S.\|last3=Nolan\|first3=T.\|last4=Sterne\|first4=J. A.\|date=2006-11\|title=Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis\|url=https://pubmed.ncbi.nlm.nih.gov/17005507\|journal=British Journal of Anaesthesia\|volume=97\|issue=5\|pages=593–604\|doi=10.1093/bja/ael256\|issn=0007-0912\|pmid=17005507}}</ref>		** Ondansetron (0.1 mg/kg single dose; maximum 4 mg) with intraoperative dexamethasone<ref>{{Cite journal\|last=Bolton\|first=C. M.\|last2=Myles\|first2=P. S.\|last3=Nolan\|first3=T.\|last4=Sterne\|first4=J. A.\|date=2006-11-01\|title=Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis\|url=https://pubmed.ncbi.nlm.nih.gov/17005507\|journal=British Journal of Anaesthesia\|volume=97\|issue=5\|pages=593–604\|doi=10.1093/bja/ael256\|issn=0007-0912\|pmid=17005507\|via=}}</ref>
	* Promethazine is associated with risk of sedation and respiratory depression in the setting of residual anesthesia and opioids <ref>{{Cite journal\|last=Starke\|first=Peter R.\|last2=Weaver\|first2=Joyce\|last3=Chowdhury\|first3=Badrul A.\|date=2005-06-23\|title=Boxed warning added to promethazine labeling for pediatric use\|url=https://pubmed.ncbi.nlm.nih.gov/15972879\|journal=The New England Journal of Medicine\|volume=352\|issue=25\|pages=2653\|doi=10.1056/NEJM200506233522522\|issn=1533-4406\|pmid=15972879}}</ref>		* Promethazine is associated with risk of sedation and respiratory depression in the setting of residual anesthesia and opioids <ref>{{Cite journal\|last=Starke\|first=Peter R.\|last2=Weaver\|first2=Joyce\|last3=Chowdhury\|first3=Badrul A.\|date=2005-06-23\|title=Boxed warning added to promethazine labeling for pediatric use\|url=https://pubmed.ncbi.nlm.nih.gov/15972879\|journal=The New England Journal of Medicine\|volume=352\|issue=25\|pages=2653\|doi=10.1056/NEJM200506233522522\|issn=1533-4406\|pmid=15972879}}</ref>

	===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===		===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===

	*High risk of '''postoperative pulmonary complications''', especially in patients with severe OSA<ref>{{Cite web\|last=Marrugo Pardo\|first=G.\|last2=Romero Moreno\|first2=L. F.\|last3=Beltrán Erazo\|first3=P.\|last4=Villalobos Aguirre\|first4=C.\|date=2018-11-01\|title=Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population\|url=https://www.hindawi.com/journals/sd/2018/1968985/\|access-date=2021-09-13\|website=Sleep Disorders\|language=en}}</ref><ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912}}</ref>		*High risk of '''postoperative pulmonary complications''', especially in patients with severe OSA<ref>{{Cite web\|last=Marrugo Pardo\|first=G.\|last2=Romero Moreno\|first2=L. F.\|last3=Beltrán Erazo\|first3=P.\|last4=Villalobos Aguirre\|first4=C.\|date=2018-11-01\|title=Respiratory Complications of Adenotonsillectomy for Obstructive Sleep Apnea in the Pediatric Population\|url=https://www.hindawi.com/journals/sd/2018/1968985/\|access-date=2021-09-13\|website=Sleep Disorders\|language=en}}</ref><ref>{{Cite journal\|last=Patino\|first=M.\|last2=Sadhasivam\|first2=S.\|last3=Mahmoud\|first3=M.\|date=2013-12-01\|title=Obstructive sleep apnoea in children: perioperative considerations\|url=https://doi.org/10.1093/bja/aet371\|journal=British Journal of Anaesthesia\|volume=111\|pages=i83–i95\|doi=10.1093/bja/aet371\|issn=0007-0912\|via=}}</ref>
	*Risk of '''postoperative hemorrhage''' and its associated adverse events, including hypoxemia (most common adverse event), bradycardia, hypotension, and difficult intubation<ref>{{Cite journal\|last=Fields\|first=Ryan G.\|last2=Gencorelli\|first2=Frank J.\|last3=Litman\|first3=Ronald S.\|date=2010-11\|title=Anesthetic management of the pediatric bleeding tonsil\|url=https://pubmed.ncbi.nlm.nih.gov/20964765\|journal=Paediatric Anaesthesia\|volume=20\|issue=11\|pages=982–986\|doi=10.1111/j.1460-9592.2010.03426.x\|issn=1460-9592\|pmid=20964765}}</ref>		*Risk of '''postoperative hemorrhage''' and its associated adverse events, including hypoxemia (most common adverse event), bradycardia, hypotension, and difficult intubation<ref>{{Cite journal\|last=Fields\|first=Ryan G.\|last2=Gencorelli\|first2=Frank J.\|last3=Litman\|first3=Ronald S.\|date=2010-11-01\|title=Anesthetic management of the pediatric bleeding tonsil\|url=https://pubmed.ncbi.nlm.nih.gov/20964765\|journal=Paediatric Anaesthesia\|volume=20\|issue=11\|pages=982–986\|doi=10.1111/j.1460-9592.2010.03426.x\|issn=1460-9592\|pmid=20964765\|via=}}</ref>

	==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==		==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==