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  1. Tonsillectomy – case presentation Moderator : Dr(Prof.) Maya Presenter: Priyankajain www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. ANKUR 16 years old male Student of class 10 th Noida ( U.P.)

  3. Chief complaints: Difficulty in breathing through nose × 13 yrs Associated with recurrent episodes of URI

  4. HOPI : The parents noticed difficulty in breathing through nose since 2-3 years of age sleeping with open mouth occasional episodes of difficulty in breathing and restlessness during sleep . no h/o morning headache , nocturnal awakening , feeling sleepy during daytime .

  5. h/o regular use of nasal decongestant drops to relieve obstruction recurrent episodes of URI once every month No current h/o fever , cough , cold, earache No h/o orthopnea, syncope, cyanosis

  6. No H/O excessive bleeding from any site blood transfusion seizures, cyanosis , drug allergy .

  7. Past history : no h/o any other medical and surgical illness . Family history : no h/o bleeding disorder Personal history : school performance good vegetarian bowel bladder habits N

  8. EXAMINATION GPE: Alert awake and cooperative Well oriented to time space and person Average build Speech quality : normal Facies : prominent nose, maxillary hypoplasia,

  9. EXAMINATION Wt : 45 kg Ht : 160 cm VITALS : PR : 80/min rt. radial , regular , normal volume and character, no radioradial and radiofemoral delay BP: 106/ 74 mm Hg , RUAS. Afebrile

  10. EXAMINATION No pallor, icterus , cyanosis , clubbing , edema Oral and airway examination : MMP I, NM and MO wnl TMD 6 cm B/L tonsils enlarged ( grade II) No deviated nasal septum B/L nostrils patent . No loose teeth

  11. Respiratory system: • Inspection : trachea central, Chest was symmetrical in shape , both sides moving equally with respiration. • Palpation : findings on inspection confirmed. • Auscultation: B/L NVBS

  12. CVS • Apex beat in 5th intercostal space midclavicular line • No visible swelling ,abnormal pulsations • S1S2 heard , no murmur

  13. Investigations: • Hb : 13.9gm/dl • TLC : 11,200/ cu mm • DLC : N 70, L 20, M 2 • Platelet : 3,04,000/ cu mm • Bleeding time : 3.15 min ( upto 7 min) • Clotting time : 6.40 min( upto 11 min)

  14. Tonsil size: grading Barash,5th edition …

  15. Anesthetic concerns • Age • URTI • OSA • Difficult airway • Airway surgery • Ponv • Pain management • Bleeding • Post op complications

  16. Post tonsillectomy bleeding: Primary : < 24hrs, generally < 6 hrs More brisk, fatal, profuse, slipping of ligatures Secondary: 24hrs – 5/6 days post op Eschar on tonsillar bed sloughs Measures: Post nasal pack Re-exploration

  17. Re-exploration: Issues: Bleeding and Hypovolemia Difficult airway Aspiration Emergency surgery full stomach with blood

  18. Anesthetic management • Assessment • Volume repletion • OT preparation : suction , iv lines large bore , • Difficult airway • Positioning • RSI • Tracheostomy

  19. Bleeding: Large bore i.v. access Correction: crystalloids ,colloids , blood Difficult to estimate blood loss: adrenergic drive, swallowing of blood HCT measurement

  20. Difficult airway: Emergent tracheostomy Experienced anesthesiologist 2 large bore suction catheters Extra laryngoscope handles and blades Cuffed ETT and stylets

  21. Anesthesia: Sedation:?? Preoxygenation Rapid sequence induction Induction: thiopentone/ propofol/ etomidate/ ketamine MR: succinylcholine/ rocuronium Gastric tube Extubation: fully awake, normal gag & cough reflexes

  22. Laryngospasm • Risk factors : Anesthesia related Inadequate depth Airway irritation with volatiles( D> I> E>H=S), mucus or blood and suction catheter or laryngoscope. Thiopentone  increase incidence Propofol< Sevo Less experience

  23. Patient related • Age • URI • Smoking • GERD • H/o choking during sleep

  24. Surgery related • T&A (21-26%) Appendicectomy, • cervical dilation, • hypospadias, • thyroid

  25. Prevention • adequate depth • Awake vs deep extubation • Positive pressure before extubation ( artificial cough) • Drugs : anticholinergics , BZD, lidocaine , magnesium ( 15mg/kg in 30 ml 0.9% NS over 20 min after intubation) • Acupunture

  26. Treatment Remove the stimulus Jaw thrust Laryngospasm notch Oral or nasal airway PPV with 100% oxygen Deepen anesthesia Drugs propofol 0.25-0.8 mg/kg Sch 0.1-3 mg/kgiv , 4 mg/kg im Doxapram 1.5 mg/kg NTG 4 g/kgiv SLN block

  27. Indications for surgery: Chronic/ recurrent tonsillitis Adenotonsillar hyperplasia with OSA Tonsillar hyperplasia Peritonsillar abscess Adenoiditis Recurrent/ chronic rhino sinusitis/Otitis media

  28. Indications: • Suspicion of malignancy • Hemorrhagic tonsillitis • Abnormal maxillofacial growth • Failure to thrive • Speech impairment • Dysphagia

  29. URI: proceed?? Higher incidence of respiratory complications but little residual morbidity Risk factors: ETT in child <5yrs Prematurity Reactive airway disease Parental smoking Airway surgery Copious secretions Nasal congestion Tait AR et al. Risk factors for perioperative adverse events in children with respiratory tract infections. Anesthesiology 2001;95:299-306 …

  30. Examination: Oral & nasal airway patency : mouth breathing, nasal quality of speech, chest retractions, wheeze, stridor, rales Adenoid facies: elongated face, high arched palate, retrognathic mandible Tonsil size: Loose teeth: age, laryngoscopy, mouth gag Syndromes

  31. Syndromes: Treacher Collins syndrome Crouzon's syndrome Goldenhar syndrome Pierre Robin C.H.A.R.G.E. association Achondroplasia Down syndrome Mucopolysccharidoses: Hunter 1& 2…

  32. Investigations: HB, Hct, Platelet count Bleeding time Clotting time X-ray: neck lateral view: adenoids PT/ aPTT vWD, factor VIII deficiency XRAY chest: LRI

  33. Premedication: Sedation: oral midazolam 0.5mg/kg Antisialagouge: dry secretions better operating field NPO Consent Blood arranged

  34. Monitoring: SPO2 ETCO2 Precordial stetho ECG Temp BP PAP Blood loss

  35. Airway management Intravenous/ inhalational Preformed RAE ETT cuffed/ uncuffed Oral packing Armoured LMA Midline fixation Brown- Davis mouth gag

  36. Anesthesia: Maint: propofol infusion/ inhalational/ muscle relaxant Spontaneous/ controlled ventilation Pain management PONV prophylaxis

  37. Armoured LMA: • Disadvantages: • Risk of aspiration • Inadequate positioning • Pilot balloon snared • Tonsillar enlargement: difficult placement Advantages: • Patent with Boyle-Davis gag • Avoid intubation& its complications

  38. LMA: In the presence of a URI : evidence that a LMA may be superior to an ETT. Some evidence that the incidence of airway complications is lower than with an ETT.Most anesthesiologists, however, prefer the intraoperative security of an ETT. Robin G. Anesthetic management of pediatric adenotonsillectomy.CAN J ANESTH 2007 / 54: 12 / pp 1021–1025..

  39. Extubation: Laryngoscopy & thorough suction Positive airway pressure: Attenuates excitation of superior laryngeal nerve & diminish laryngospasm Expel secretions Maintain oxygenation Awake/ deep Lateral position, head down

  40. Laryngospasm: Prevention: Deep extubation/ fully awake (OSA) I.V. lidocaine Topical anesthesia Magnesium CPAP at extubation

  41. Pain management: NSAIDS Opioids Local infiltration TENS

  42. NSAIDS: NSAIDs did not cause any increase in bleeding requiring return to theatre. There was significantly less nausea & vomiting when NSAIDs were used compared to alternative analgesics. Cardwell et.al. Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy.Cochrane Database of Systematic Reviews 2005, Issue 2.

  43. NSAIDS: Francis et al. Analgesics for postoperative pain after tonsillectomy and adenoidectomy in children. (Protocol) Cochrane Database of Systematic Reviews 2007, Issue 3.

  44. Opioids: Decreased doses in OSA Opioid sparing effect of NSAIDS

  45. Local anesthetic: Bupivaciane infiltration pre and post surgery, with & without adr, spray Reduces bleeding No evidence that the use of perioperative LA in Pts undergoing tonsillectomy improves post-operative pain Hollis LJ et al. Perioperative local anesthesia for reducing pain following tonsillectomy.Cochrane Database of Systematic Reviews 1999, Issue 4.

  46. TENS: TENS for post tonsillectomy pain relief is a safe, easy and promising method over alternative analgesic regimes which can be safely employed by the recovery staff. A.K.Gupta et al. POST - TONSILLECTOMY PAIN : DIFFERENT MODES OF PAIN RELIEF. Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 2, April - June 2002…

  47. PONV: Incidence: 40-70% Irritant blood in stomach Inflammation/ edema Dehydration: poor oral intake Prophylaxis: Maintain adequate hydration Gastric decompression Antiemetic drugs Acupuncture

  48. Antiemetics: Good evidence: prophylactic anti-emetic effect of dexamethasone, ondansetron, granisetron, tropisetron & dolasetron, metoclopramide are efficacious. Not sufficient evidence: dimenhydrinate/ perphenazine/ droperidol/ gastric aspiration/ acupuncture are efficacious C. M. Bolton et al. Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: A systematic review and meta-analysis.Br J Anaesth 2006; 97: 593–6041

  49. Antiemetics: Concealed hemorrhage: with tropisetron, ondansetron P G Herreen et al. Concealed post-tonsillectomy hemorrhage associated with the use of the antiemetic; Anesthesia and Intensive Care; Aug 2001; 29, 4

  50. PACU: Bleeding: Pain: Obstruction: PONV: severe C/I Oral intake not required for discharge Adenoidectomy: safely discharged