Principles of Anesthesia In Tonsillectomy Surgery in Children
27th International Rhinocamp Congress, Muğla, Türkiye, 25 - 28 Mayıs 2023, ss.122-123, (Tam Metin Bildiri)
- Yayın Türü: Bildiri / Tam Metin Bildiri
- Basıldığı Şehir: Muğla
- Basıldığı Ülke: Türkiye
- Sayfa Sayıları: ss.122-123
- Erzincan Binali Yıldırım Üniversitesi Adresli: Hayır
Özet
Principles of Anesthesia In Tonsillectomy Surgery in Children
Tülay Ceren Ölmeztürk Karakurt MD
Anesthesiology and Reanimation Clinic, Erzincan Binali Yıldırım University, Mengücek Gazi Training and Research Hospital, Erzincan, Türkiye
Tonsillectomy is one of the most common surgical procedures performed in children. Airway obstruction, recurrent
infection and resulting in sleep-disordered breathing or obstructive sleep apnea (OSA) are the most common
indications for tonsillectomy.The following features make airway management for tonsillectomy particularly
challenging:
The airway is shared between the anesthesiologist and the surgeon and must be protected from blood and secretions.
The incidence of laryngospasm is higher than during other surgical procedures.
Children who undergo the procedure for OSA are at particularly high risk of significant respiratory complications in
the postoperative period.
Preanesthetic evaluation:
Upper respiratory infections (URI) are common in children presenting for tonsillectomy and may affect the timing
of surgery, as recent URI increases the risk of perioperative adverse respiratory events. Preoperative evaluation in
anticipation of tonsillectomy should pay particular attention to the likelihood and severity of obstructive sleep apnea
(OSA) and of bleeding disorders.
•
•
•
•
•
•
Overarching goals of anesthetic management include:
Smooth, atraumatic induction of anesthesia
Protection of the airway during surgery
Provision of postoperative analgesia
Prevention of postoperative nausea and vomiting (PONV)
Smooth, rapid emergence to allow recovery of airway protective reflexes and avoidance of airway obstruction
and respiratory depression
Premedication:
For most children undergoing tonsillectomy, we use distraction techniques (eg, videos, songs, mobile computing
devices) and parental presence rather than premedication with anxiolytics. The goal is to calm the child while avoiding
the sedative and respiratory depressant effects of anxiolytics.
Positioning:
Tonsillectomy is performed in a standard supine position with the neck extended. The head and neck should be
positioned carefully for intubation and surgery. This is particularly important for children with down syndrome, who
have a high incidence of atlantoaxial instability, often without symptoms. In addition, neck extension can move the
endotracheal tube and cause inadvertent extubation, especially in small children.
Induction technique:
For young children (≤6 years of age) without severe obstructive sleep apnea (OSA), we perform inhalational induction
of anesthesia with sevoflurane. For older children (≥12 years of age), we prefer intravenous (IV) induction to allow
more rapid induction and airway control. For children between 6 and 12 years of age, the induction technique
depends on the child’s level of anxiety and ability to tolerate IV placement.
For children of any age with severe OSA or for children with multiple risk factors for perioperative respiratory adverse
events, we prefer an IV induction whenever possible. If inhalational induction is necessary for these children, IV access
should be obtained as soon after induction as possible.
Airway management:
We prefer a cuffed endotracheal tube rather than an uncuffed endotracheal tube or laryngeal mask airway for airway
management in order to protect the airway from bleeding, secretions, and the risk of fire with the use of electrocautery.
Maintenance of anesthesia:
We maintain anesthesia with sevoflurane.
12227th R hino c amp Meeting Proceedings
Analgesia:
We use a multimodal approach to pain control, which includes prophylaxis with intraoperative IV acetaminophen (15
mg/kg), usually in combination with a low-dose opioid (fentanyl 1 mcg/kg IV). Opioid doses are reduced for children
with obstructive sleep apnea. Nonsteroidal antiinflammatory drugs (NSAIDs) are effective at reducing the dose of
opioid required for postoperative pain control, but they may increase the risk of bleeding.
Pain is an important cause of morbidity after tonsillectomy and can result in dysphagia, decreased oral intake,
dehydration and weight loss. Pain is worst in the first few postoperative days but significant pain may last up to two
weeks.
Antiemetics:
PONV is decreased by the use of intraoperative a serotonergic antagonist (eg, ondansetron 0.1 mg/kg IV).
Emergence from anesthesia:
Emergence from anesthesia after tonsillectomy can be a challenge as children who undergo tonsillectomy are at high
risk of laryngospasm and increased airway reactivity. To minimize the possibility of laryngospasm, the oropharynx
should be thoroughly suctioned prior to emergence to remove blood and secretions. All children should be extubated
and positioned for recovery in the lateral position with the neck slightly extended to allow secretions to drain away
from the oropharynx. All children should be cared for until wide awake by clinicians who are experienced in basic
airway support, such as jaw thrust and oral or nasal airway placement.
We extubate most patients after tonsillectomy awake. Awake extubation allows the return of airway tone and airway
protective reflexes, and theoretically reduces the risk of post-extubation airway obstruction and laryngospasm.
In patients with risk factors for difficulty with airway management (eg, craniofacial anomalies) awake extubation is
preferred.
Keywords: Anesthesia, Tonsillectomy Surgery, Children
References:
1. Hosseini H, Ayatollahi V, Rahimianfar AA, Rahimianfar F. The Effect of Low-Dose of Propofol on the Respiratory Complications Immediately After
Tracheal Extubation in Children Undergoing Tonsillectomy. Indian J Otolaryngol Head Neck Surg. 2022;74(Suppl 3):5147-5150. doi:10.1007/s12070-
021-03037-2
2. Adler AC, Daszkowski A, Tan JC, et al. The Association of Dexmedetomidine on Perioperative Opioid Consumption in Children Undergoing
Adenotonsillectomy With and Without Obstructive Sleep Apnea. Anesth Analg. 2021;133(5):1260-1268. doi:10.1213/ANE.0000000000005410
3. Di M, Han Y, Yang Z, et al. Tracheal extubation in deeply anesthetized pediatric patients after tonsillectomy: a comparison of high-concentration
sevoflurane alone and low-concentration sevoflurane in combination with dexmedetomidine pre-medication. BMC Anesthesiol. 2017;17(1):28.
Published 2017 Feb 21. doi:10.1186/s12871-017-0317-3.
4. Rabbani CC, Pflum ZE, Ye MJ, et al. Intraoperative ketorolac for pediatric tonsillectomy: Effect on post-tonsillectomy hemorrhage and perioperative
analgesia. Int J Pediatr Otorhinolaryngol. 2020;138:110341. doi:10.1016/j.ijporl.2020.110341
5. Bolton CM, Myles PS, Nolan T, Sterne JA. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-
analysis. Br J Anaesth. 2006;97(5):593-604. doi:10.1093/bja/ael256