Anaesthetic management of Tonsillectomy in pediatric patients

Indication for tonsillectomy
* chronic or acute recurrent tonsillitis
* peritonsillar abscess formation
* obstructive tonsillar hyperplasia
Pathophysiology of recurrent acute tonsillitis
Tonsillar hyperplasia ~> chronic airway obstruction ~>sleep apnoea~> hypoxia and CO2 retention
                                                                                                         |                              
                                                Increased airway pressure and pulmonary vasoconstriction
                                                                                                        |
                  Pulmonary artery hypertension and right heart failure~> cor pulmonale
Preoperative Evaluation

1. H/o frequent infections
2. Current use of antibiotics and antihistamines 
3. H/o sleep apnoe

Physical examination

• Presence of audible respirations / mouth breathing/ nasal quality of speech
• Facies - elongated face, retrognathic mandible and high arched palate
• Chest retractions
• Airway- evaluation of tonsillar size,presence of wheeze or rales,inspiratory stridor
• Investigations- haematocrit, coagulation parameters,chest radiograph,electrocardiograph last 2 required if recent pneumonia and bronchitis 

Anaesthetic management

Premedication

* Sedative premedication is avoided in view of maintaining airway latency

* antisialogogue is used to minimise secretions

Induction

 1)  Volatile anaesthetic induction with mask ( parental presence in anxious unpremeditated child)

 2).  Tracheal induction with deep inhalation / aided with short acting muscle relaxants( supraglottic region is packed with gauze and cuffed endotracheal tube to prevent pharyngeal blood to seep into trachea

Monitors 

1) Precordial stethoscope

2) Electrocardiograph 

2) Automated blood pressure

3) Pulse oximetry

4) end tidal CO2

Emergence

Should be rapid and child should be alert to maintain airway prior to shifting to recovery

Complications 

1) Emesis. Maybe due to irritant blood in the stomach or due to airway stimulation caused by inflammation and edge a of surgery,treated with ondansetron 0.1 mg to 0.15mg with or without dexamethasone

2) Post operative haemorrhage. 75% of post operative haemorrhage is in the first 6 hours of surgery and the next 25% is the next 24 hours

Treatment is by pharyngeal packing and electro cautery,sometimes patients are returned to OR for reexploration

In the above scenario patient is considered full stomach, intubated with rapid sequence 

Meticulous fluid management with strict blood pressure monitoring

Post operative pain is managed with acetaminophen and corticosteroids to reduce inflammation and edema