Paediatric adenotonsillectomy, part 2: considerations for anaesthesia.
- Children scheduled for AT and deemed at increased risk of perioperative respiratory events need to observed in hospital overnight.
- A suggested approach to risk stratification for overnight monitored admission vs. daycare surgery involves looking at age <3 years, comorbidities, AHI >10 if sleep study available or SaO2 <80% on PSG. If a sleep study is not available, surrogates including screening questionnaires and overnight pulse oximetry, audiovisual recording and nasal endoscopy may be used.
- The McGill oximetry score is useful in perioperative risk stratification.
- Data from Europe suggests age <3 years should be used as a starting point in discussion of risk stratification due to the higher prevalence of severe critical events in this age group seen in the literature. Age <3 years alone does not necessarily imply tertiary paediatric level centres should be used.
- Experienced paediatric anaesthetists should look after higher risk children undergoing AT with careful opioid titration and sedation.
- Pain management should be multimodal and opioid sparing. Drugs facilitating upper airway muscle relaxation should be used with caution.
- Alpha 2 agonists and ketamine have the least impact on blunting airway neuromotor function. Alternatives to benzodiazepine premedications include parental presence at induction and use of alpha agonist premedications.
- Multiple factors influence pain scores after AT including pharmacogenomics. Halving of opioid doses is recommended. Controversy remains regarding the use of NSAIDs. NSAIDs can predispose to increased postoperative bleeding but do significantly improve analgesia. Options include selective COX-2 inhibitor drugs. If ibuprofen is used, delaying administration until after surgery is recommended.
- A single dose of intraoperative dexamethasone can increase bleeding but benefits outweigh risks.
- Local anaesthetics provide only a modest reduction in resting pain. Increased pharyngeal collapsability may be an unintended consequence.
Reviewed by Dr. Katherine Lanigan