Adapted from John Hunter guideline 8.2 (Australia) for PCEA Tumutumu
Hospital Kenya
GUIDELINE OBJECTIVE:
This guideline aims to assist clinical staff to provide effective care to paediatric
patients
following a tonsillectomy/ adeno-tonsillectomy by providing guidelines on:
Recognition and management of primary haemorrhage
Recognition and management of airway compromise
Effective pain relief
Safe maintenance of hydration
Minimisation of post-operative nausea and vomiting
Information on discharge
The three principal post-operative complications of
tonsillectomy/adenotonsillectomy are:
1. Bleeding – primary haemorrhage,
2. Airway obstruction
3. Fluid mismanagement – iatrogenic hyponatraemia
Factors associated with an increased risk of post tonsillectomy/adenotonsillectomy haemorrhage include:
Coagulopathy
Increasing age of child
Quinsy (peri-tonsillar abscess) tonsillectomy
Factors associated with an increased risk of post tonsillectomy/adenotonsillectomy airway obstruction include:
Increasing Respiratory Disturbance Index (RDI), especially in Rapid Eye
Movement (REM) phase – that means events such as apnoea, hypoventilation,
respiratory distress that occur during sleep
Severe Obstructive Sleep Apnoea (OSA)
March 2015
For review March 2016
Cranio-facial syndromes, mucopolysaccharidoses, achondroplasia, Pierre Robin
sequence, Down syndrome, some neuromuscular diseases
Factors associated with an increased risk of post tonsillectomy/adenotonsillectomy iatrogenic hyponatraemia include:
Using solutions other than Normal Saline or Hartmann’s Solution in the first 24
hours (other solutions contain too much water for the immediate post-operative
period)
vomiting
CLINICAL GUIDELINES:
Considerations for post-op Paediatric Intensive Care Unit (PICU) admission.
Tumutumu does not have an intensive care unit. Therefore nursing and medical staff
to seek clarification from paediatric and surgical senior staff on appropriate care post
tonsillectomy in addition to guidelines set out below, as well as consideration for
tonsillectomy to be done in a centre that does have a PCIU:
Isolated Respiratory Disturbance Index (RDI) in Rapid Eye Movement (REM)
sleep greater than 60.
RDI in REM less than 60 plus consideration of
- a syndrome likely to be complicated by airway obstruction (eg cranio-facial
anomalies, mucopolysaccharidoses, achondroplasia, Pierre Robin
sequence, Down syndrome), or
- age less than 24 months,
- weight for height Z score less than -2SD or MUAC <12.5cm
- significant neuromuscular disease or respiratory compromise, or significant
central component > 40%.
i.e. not obstructive – can be complicated by troublesome hypoventilation
Severe OSA as determined by a sleep study- PSG
Complex cyanotic/ congenital heart disease
After discussion amongst Surgeon, Anaesthetist, and Intensivist
March 2015
For review March 2016
1. Observations: (unless ordered otherwise)
1.1Pulse, Respirations and Oxygen Saturations every 15 minutes until “Post –Op
Stable” as defined by the criteria below.
Vital signs monitoring should be supervised by a trained nurse and must be checked
against the normal parameters for children according to age category (poster of
paediatric vital signs at nurses station in ward 2 for reference).
1.2 Blood pressure as directed by the surgeon
“Post –Op Stable” is defined as:
awake
protecting their airway
with adequate analgesia
not vomiting
haemodynamically stable (vital signs in normal parameters)
Ideally a patient should be completely “Post-op Stable” prior to transfer back to ward,
if does not meet all the above criteria, inform the surgical team and continue vital
signs every 15 minutes until stable.
Patients MUST be transferred with all post-operative instructions, drug chart
and IV prescription chart and vital signs documented in patient notes by the
surgeon and anaesthetist. Do not transfer the patient back to the ward without
them.
Post Op Stable further monitoring:
(unless ordered otherwise)
1.4 Record observations vital signs chart including pulse, oxygen saturations and
respirations half hourly for a further 4 hours then,
1.5 Pulse and respirations hourly for 20 hours, or for as long as indicated by the
medical officer, then 4 hourly till discharge,
1.6 Temperature 4 hourly,
1.7 Blood pressure 4th hourly for children > 12 years.
Call surgical team if oxygen saturations reading < 92% (ensure trace is good).
1.8 Re-evaluate child periodically to determine whether additional treatment/
supports are required eg. oxygenation, positioning
March 2015
For review March 2016
* Report abnormal observations promptly to the appropriate medical officer*
2 Observe for:
2.5 Behavioural disturbances eg. odd sleeping position, restlessness, agitation,
sleepiness, and irregular breathing pattern - these indicators may be due to
hypoxia.
2.6 Frank bleeding from the nose or mouth
2.7 Excessive swallowing or Frequent clearing of throat
2.8 Tachycardia
2.9 Pallor and sweating
2.10 Nausea and vomiting - inspect vomitus for fresh blood
IN AN EMERGENCY CALL THE , Medical Officer, PAEDIATRICIAN
and SURGEON
3 Pain Management Rationale:
The literature suggests:
children may experience significant pain after tonsillectomy
regular pain relief is more effective than prn
regular paracetamol is the mainstay of effective analgesia
3.1 Pain Management:
Paracetamol doses should be calculated based on body weight
Oral administration of paracetamol is preferred, but the rectal and IV routes may
be used for acute, short- term treatment
Other analgesics may be prescribed by the anaesthetist in liaison with the
Surgical team.
Ibuprofen (Nurofen) and other non-steroidal anti-inflammatory drugs should be
avoided unless specifically prescribed due to risk of bleeding.
March 2015
For review March 2016
Refer to regular and PRN medication charts.
NB- Opioids to be used with caution
Children with a history suggestive of sleep apnoea are particularly sensitive to
the respiratory depressant effects of opioids and sedative agents
In the ward areas, note that the restless child may be hypoxic due to blood loss
or respiratory depression/sleep apnoea
Check pre-op and anaesthetic record for medications already given, and their
timing, before administering regular or PRN analgesics.
4 Fluids- Choice of IVF replacement therapy is very important to avoid iatrogenic
Hyponatraemia
4.1 Outside of PICU Hartmann’s Solution or Normal Saline only are to be
administered in the first 24hrs post op.
Note: Hartmann’s Solution has a number of medication incompatibilities so check
any additives.
4.2 Encourage oral fluids and document all intake and output on a fluid balance
chart.
5 Medications for Nausea/Vomiting:
5.1 If nausea or vomiting persists, the child is to be reviewed by the Surgeon/
Medical Officer before discharge.
6 Indicators for patient discharge:
6.1Tolerating soft diet, advancing to regular diet.
6.2 Adequate oral intake – according to age and underlying medical conditions (or
as advised by the Surgeon).
6.2 Post operation void has occurred before discharge.
6.3 Parent/carers are confident to take their child home.
7 Discharge Plan:
March 2015
For review March 2016
Ensure parent / carer has:
7.1Discharge information
7.2 Follow up appointment
7.3 Discharge prescription (eg for antibiotics) if ordered
7.4 Contact phone number- to direct concerns
Discharge Criteria:
Vital signs are stable and within normal limits
Tolerating fluid, advancing to normal diet
Nil vomiting
Has voided post operatively
Pain controlled by oral analgesia
Information on post-op. care & contact telephone numbers provided to carers.
March 2015
For review March 2016