Adenotonsillectomy. A safe outpatient procedure

Effectiveness of bismuth subgallate for preventing bleeding following adenotonsillectomy: A multicentre study

BACKGROUND

Tonsillectomy and adenotonsillectomy are surgical procedures routinely performed worldwide, with various complications, including postoperative bleeding (PTH). Among haemostatic agents, bismuth subgallate (BS) has been employed in the past decades, but its use is controversial in children.

OBJECTIVE

This retrospective, multicentre study aims to evaluate the effectiveness and safety of BS in preventing PTH following tonsillectomy and adenotonsillectomy.

MATERIALS AND METHODS

Two cohorts of children between 0 and 18 years of age were compared in two different hospitals. The first (active) group of patients included children who underwent tonsillectomy/adenotonsillectomy performed using BS added to gauze swabs, whereas this agent was not administered to the second (control) group. The following variables were analysed: age, gender, degree of tonsillar hyperplasia, length of hospital stay, acute complications (including bleeding and infection), further admissions to the Paediatric Emergency Department (PED), and further hospital admissions in the 30 days postoperatively.

RESULTS

Four-thousand- seven hundred forty-four children were included in the study, 2598 in the active group and 2146 in the control group. The cases included in the active treatment group displayed a significantly reduced PTH prevalence, 1.4 versus 2.6 % (p < 0.05). No cases of neurological complications or aspiration pneumonia were detected.

CONCLUSIONS

This study supports BS as a safe and reliable option for preventing severe PTH following tonsillectomy/adenotonsillectomy.

Predictors of Occurrence and Timing of Post-Tonsillectomy Hemorrhage: A Case-Control Study

OBJECTIVE

To describe cases and timing of pediatric post-tonsillectomy hemorrhage (PTH), to evaluate predictors of PTH, and to determine the optimal amount of postoperative care unit (PACU) monitoring time.

STUDY DESIGN

Using the Pediatric Health Information System (PHIS) database and electronic medical records, a matched case-control study from 2005 to 2015 was performed.

SETTING

A single, tertiary-care institution.

SUBJECTS AND METHODS

Each case of PTH was matched with 1 to 4 controls for the following factors: age, sex, surgeon, and time of year. A total of 124 cases of PTH and 479 tonsillectomy controls were included. The rate and timing of postoperative bleeding were assessed, and matched pair analysis was performed using conditional logistic regression.

RESULTS

Our institutional PTH rate of 1.9% (130 of 6949) included 124 patients; 15% (19) were primary (≤24 hours), with 50% (9) occurring within 5 hours. Twenty-one percent (4 of 19) of primary PTH patients received operative intervention. Eighty-five percent (105 of 124) of all cases were secondary PTH, and 47% (49) of those patients received operative intervention. Cold steel (OR 1.9, 95% CI 1.1-3.3) and Coblation (OR 1.9, 95% CI 1.2-3.1) techniques and tonsillectomy alone (OR 3.7, 95% CI 1.9-7.2) increased odds of PTH. Patients who developed PTH had 4 times the odds of having a preceding postoperative respiratory event than controls (OR 4.0, 95% CI 1.6-10.0).

CONCLUSION

We conducted a rigorous case-control study for PTH, finding that PTH was associated with use of cold steel and Coblation techniques and with tonsillectomy alone. Patients with a postoperative respiratory event may be more likely to develop a PTH and should be counseled accordingly. A PACU monitoring time of 4 hours is sufficient for outpatient tonsillectomy.

Topical biomaterials to prevent post-tonsillectomy hemorrhage

Despite advances in surgical technique, postoperative hemorrhage remains a common cause of mortality and morbidity for patients following tonsillectomy. Application of biomaterials at the time of tonsillectomy can potentially accelerate mucosal wound healing and eliminate the risk of post-tonsillectomy hemorrhage (PTH). To understand the current state and identify possible routes for the development of the ideal biomaterials to prevent PTH, topical biomaterials for eliminating the risk of PTH were reviewed. Alternative topical biomaterials that hold the potential to reduce the risk of PTH were also summarized.

Effect of Suturation Plus Surgicel Application on Post-Tonsillectomy Bleeding and Pain

OBJECTIVE

The aim of this study was to evaluate the effect of suturation (tonsillary fossa closure) plus Surgicel application on postoperative bleeding and pain after tonsillectomies performed using a classical dissection method.

STUDY DESIGN

A prospective, randomized, double-blind, clinical trial was performed on 760 patients undergoing tonsillectomy or adenotonsillectomy during a 5-year period.

METHODS

After excluding patients with hemorrhagic disorder, chronic disease, and peritonsillar abscess, both tonsils were removed via classic dissection technique (cold knife or blunt dissection) and then electrocauterized for hemostasis. The tonsillar fossa randomly assigned to the treatment protocol (Group 1) was closed by sutures, following Surgicel application. The other side was unaltered and acted as the control (Group 2). Pain was evaluated every day for 10 days postoperatively, and bleeding was reported at any time.

RESULTS

A total of 760 patients (393 males, 367 females) between the ages of 4 and 35 years (mean age 13.46 ± 7.98) were included in the study. Bleeding was observed in 31 patients: 8 from Group 1; and 23 from Group 2 (95% confidence interval [CI], P < 0.05). The average pain score was greater in Group 1 than in Group 2 on each postoperative day (95% CI, P < 0.05).

CONCLUSION

Suturation plus Surgicel application increased pain levels while decreasing bleeding incidence during the postoperative period.

Bismuth subgallate as a topical haemostatic agent at the palatal wounds: a histologic study in dogs

This study evaluated the early recovery process of the palatal wounds of dogs using bismuth subgallate. Five healthy adult male dogs underwent eight 5-mm partial-thickness punch biopsies in two paired columns on the palatal mastigatory mucosa. For the haemostasis, one side received moistened gauze pressure (test group 1), and the other received bismuth subgallate (test group 2). A description of the epithelium and connective tissue repair was made at 3, 7, 14 and 21 days. During the first days, a mass of disorganized tissue covered the connective tissue, in which there was intense chronic inflammation, and migration of epithelium cells from the edges towards the central region to close to the wound was seen. The final evaluation demonstrated well organized epithelial and connective tissues in all the samples. Epithelium thickness was measured at 0, 14 and 21 days, from images of the digitalized histological sections. In comparisons between the test groups, the bismuth subgallate group was slightly better than the saline group, but no statistically significant difference was found at 21 days. It was possible to conclude that bismuth subgallate did not interfere in the tissue repair of the palatal mastigatory mucosa in dogs.

Life-threatening posttonsillectomy hemorrhage

OBJECTIVES/HYPOTHESIS

In rare cases, the intensity of posttonsillectomy hemorrhage (PTH) may become life-threatening requiring major surgical means and intensive care. This study was conducted to assess the outcome of life-threatening PTH and its clinical features in a larger patient population.

STUDY DESIGN AND METHODS

Cases occurring during the clinical career of the authors were collected and added by own expert reports to lawsuits and professional boards in cases who had undergone tonsillectomy elsewhere. PTH resulting in hemorrhagic shock requiring resuscitation, ligature of greater arteries in the neck, tracheotomy, packing of the pharynx, embolization, and/or blood transfusions were labeled as life threatening.

RESULTS

Seventy-nine patients had experienced life-threatening PTH between 1980 and 2006, comprising 36 children and 39 adults (age not stated for 4 patients). There were 42 female and 34 male patients (gender not stated for 3 patients). Only nine patients experienced primary bleeding, secondary PTH clearly prevailed (n = 70; 89.6%) in this patient population. Single episodes of life-threatening PTH were reported for 11 cases including two patients with and nine without remaining neurological sequelae. Three of the 11 patients were children (age not stated for 2 patients). Repeated episodes of life-threatening PTH occurred in 68 patients (32 children) including eight with remaining sequelae.

CONCLUSIONS

Life-threatening PTH is an apparently rare, most commonly unpredictable state of emergency requiring a clear management protocol. However, repeated episodes of bleeding classified most clinical courses and should alert the medical staff. Although the bleeding rate after tonsillectomy in children is generally acknowledged to be very low, the rate of life-threatening PTH is apparently higher than in adults. Gender seems not to be a risk factor. Secondary PTH can no longer be assessed to be less dangerous than primary PTH.

Serious post-tonsillectomy hemorrhage with and without lethal outcome in children and adolescents

BACKGROUND

Serious post-tonsillectomy hemorrhage (PTH) is an uncommon complication requiring immediate and adequate medical treatment. This study was undertaken to describe and evaluate the clinical data and courses of serious PTH, with and without lethal outcome in children and adolescents.

MATERIALS AND METHODS

Bleeding episodes accompanied by hemorrhagic shock requiring resuscitation and/or major medical treatment were labeled as serious PTH, with or without lethal outcome. Personal experiences as surgeons and expert reports in connection with lawsuits and Professional Boards, as well as reports collected after a published request contributed to the data collection.

RESULTS

Thirty-one boys and 21 girls (gender not stated for three patients) younger than 18 years of age were enrolled in our study (mean: 8.47; median: 6; S.D.: 4.73 years). Thirty-three children were 8 years of age or younger (60%). Lethal outcome was reported for 19 patients of whom 11 had experienced repeated episodes of bleeding. The majority of the surviving children experienced serious PTH without remaining sequelae (32), however, four children suffered from remaining sequelae. Forty-three children experienced repeated episodes of PTH. The first episode of PTH occurred either at home (32) or in the hospital (22; location not stated for one child). Primary hemorrhage (<24h) was reported for three, secondary bleeding (>24h) for 52 children (94.5%). A total of 169 bleeding episodes was reported of whom 149 were specified as massive (56), major (31), minor (15), diffuse (12), with spontaneous cessation (19) or vomiting of considerable amounts of blood (16). Aspiration was confirmed at the autopsy of seven patients. Ligature of greater arteries in the neck was performed in 35 cases, suturing of the faucal pillars in four and packing of the oropharynx in six patients. Twenty-four children received blood transfusions. Resuscitation was performed in 17 cases but remained ineffective in seven patients.

CONCLUSION

Repeated episodes of bleeding should be considered as a warning sign of serious PTH. Inpatient observation does not eliminate the risk of lethal outcome. Children up to 8 years of age seem to be more susceptible to serious PTH, whereas gender remained irrelevant as a contributing risk factor. Life-threatening PTH is likely to occur as secondary PTH.

Influence of meteorological conditions on post-tonsillectomy haemorrhage

Aim:

To evaluate the relationship between the incidence of primary post-tonsillectomy haemorrhage and the daily weather condition, over a five-year period.

Study design and setting:

This was a retrospective study carried out in the ENT department of the Split University Hospital between January 2000 and December 2004.

Results:

Out of 3377 patients undergoing tonsillectomy, primary post-operative haemorrhage occurred in 83 (2.5 per cent). The season, daily atmospheric pressure and daily change in atmospheric pressure did not have any significant influence on post-tonsillectomy haemorrhage incidence. However, there was a statistically significant increase in the incidence of primary post-operative haemorrhage when cyclonic conditions prevailed (p = 0.035).

Conclusion:

The incidence of primary post-tonsillectomy haemorrhage in our study population was 2.5 per cent. Avoiding tonsillectomy during cyclonic weather conditions may reduce the incidence of primary post-tonsillectomy haemorrhage.

Adult tonsillectomy and day care surgery

OBJECTIVE

To evaluate the safety of adult tonsillectomy as a day care surgery

METHODS

Records of 664 patients above the age of 12 years, who underwent tonsillectomy were analysed. These patients were operated in our department within January 1999 and September 2002. Only 13 patients (1.95%) had post operative bleeding and were readmitted after discharge. The data of these patients were collected from medical records as well from the morbidity meeting proceedings and was reviewed retrospectively. Statistical analysis was done by using 'one sample t-test'.

RESULTS

Overall incidence of post operative bleeding was 1.95%. None of our pateients bled with 12 hours of Surgery, 0.3% had bleeding between 12 to 24 hours after tonsillectomy and 1.65% encountered bleeding between 24 hours to the 6th post operative day. Bleeding was not major in majority of patients as only 0.45% of the patients required second anesthesia to control the bleeding and only 0.35% of patients required blood transfusion to replace the lost blood volume. In addition, higher incidence of bleeding was seen in males, in the older age group of 31-40 years, patients with obstructive sleep aponea and in patients where tonsillectomy was done by electrocautry dissection.

CONCLUSION

Based on these observations, we conclude that Adult tonsillectomy can be safely preformed in our setup.

A telephone audit in parallel with the UK national tonsillectomy audit to investigate re-admission as a measure of secondary haemorrhage rate

OBJECTIVES

An audit to run in parallel with the remaining 5 months (at the time of conception) of the national tonsillectomy audit to examine the accuracy of re-admission following bleeding as a measure of secondary haemorrhage rate.

METHODS

A retrospective, case series audit of all patients undergoing tonsillectomy between 29th April and 1st October 2004 at Frimley Park Hospital a UK District General Hospital. One hundred and twenty-nine patients (adults and children) undergoing tonsillectomy were contacted by telephone 2 weeks after surgery. The main outcome measures were reported bleeding and re-admission. We reviewed all studies reported in the literature investigating secondary haemorrhage rate in the community.

RESULTS

This study demonstrated 19% (n=24) of patients experienced bleeding post-operatively. Ten per cent (n=13) returned to hospital for advice and were admitted. The literature review shows the variability of the proportion of patients with bleeding that are re-admitted is 33.3 standard deviations.

CONCLUSIONS

There are widely different regional re-admission rates for post-tonsillectomy secondary haemorrhage. Re-admission is an unreliable measure of secondary haemorrhage. Change of practise based on conclusions drawn from re-admission rates are unsound.

Evaluation of bismuth subgallate and adrenaline paste as haemostat in tonsillectomy bleeding

Haemorrhage is a frequent and often feared complication of tonsillectomy. This has prompted the use of a variety of topical haemostatics such as bismuth subgallate to achieve haemostasis and reduce the risk of postoperative haemorrhage. In this study effect of bismuth subgallate and adrenaline paste was investigated. A total of twenty five subjects undergoing tonsillectomy were randomly recruited. The distinctive feature of study was that each patient constituted a matched pair, with left tonsillar fossa acting as control and right tonsillar fossa as trial side. Bismuth subgallate adrenaline paste was made by mixing 13 gm of Bismuth subgallate powder with 10 ml of normal saline and 0.35 ml of 1: 1000 adrenaline. The application of twin reagent paste resulted in reduced blood loss in trial fosse (60.8 ± 19.3 ml) as compared to control fossa (91.2 ± 20.27) (p < 0.0001). Similarly the average number of ligatures applied to control bleeding was also less in trial fosse. Only one patient reported reactionary haemorrhage while there was no report of secondary haemorrhage from amongst tonsillar fosse on trial side. However, two patients presented with secondary haemorrhage from control side fosse.

Adult ENT day surgery: a case for expansion of services

Day case surgery is acknowledged to have many advantages over inpatient surgery, including greater efficiency, reduced risk of infection, reduced waiting lists and lower costs. 1 Although in the past two decades day surgery has experienced a gradual expansion of services in the UK, the 2001 Audit Commission report on day surgery showed that there was still far more potential for expansion 2 and the Department of Health launched the 'day surgery strategy' in January 2002 with the specific aim of increasing and improving day surgery in the NHS.

Topical adrenaline in the control of intraoperative bleeding in adenoidectomy: a randomised, controlled trial

OBJECTIVES

To evaluate the efficacy of topical racemic adrenaline (RA) (Micronefrin; Bird Products, Palm Springs, CA, USA) in the control of intraoperative bleeding and the prevention of postoperative bleeding, laryngeal spasm and postoperative pain in adenoidectomy among children <6 years of age.

DESIGN

Prospective, randomised, blinded and placebo-controlled trial.

SETTING

Kanta-Hame Central Hospital, a district referral center in Finland.

PATIENTS

A consecutive sample of 93 children undergoing outpatient adenoidectomy.

INTERVENTION

Patients were randomised to receive topical gauze sponges soaked in either 1:500 RA or 0.9% sodium chloride (physiological saline) for 3 min after adenoidectomy.

MAIN OUTCOME MEASURES

Amount of intraoperative bleeding (surgeons' subjective estimate), need for additional packings, need for electrocautery, laryngeal spasm, postoperative bleeding and pain, duration of procedure and duration of patients' stay in the operation room (OR).

RESULTS

Adrenaline significantly decreased surgeons' subjective estimate of the amount of intraoperative bleeding (proportion of patients with significant decrease 67 versus 21%, P < 0.001), reduced the mean number of packings needed (0.6 versus 1.2, P < 0.001) and use of electrocautery (22 versus 45%, P = 0.015), and shortened the mean duration of the procedure (13 versus 18 min, P = 0.043) and the mean stay in the OR (31 versus 35 min, P = 0.058). The impact of adrenaline was even more pronounced among patients with extensive adenoids and/or profuse intraoperative bleeding. A slight elevation of heart rate was observed more often in the adrenaline group (P = 0.043).

CONCLUSIONS

Use of topical adrenaline can be recommended in adenoidectomy among children. It helps control the intraoperative bleeding, reduces the use of electrocautery and shortens the durations of procedure and stay in the OR.

The role of oral fluid intake following adeno-tonsillectomy

OBJECTIVE

To compare the incidence of complications following pediatric adeno-tonsillectomy (T&A) in patients who are encouraged to drink oral liquid versus patients who drink on a voluntary basis.

METHODS

This is a prospective, randomized, non-blinded study performed in a tertiary care medical center. Ninety-three otherwise healthy pediatric patients aged 2-12 years undergoing ambulatory T&A by a single surgeon were included in the study. Forty four patients were encouraged to drink 240 ml of clear liquid prior to discharge while 49 patients drank on a voluntary basis. Patients were followed prospectively for the incidence of emesis, dehydration and other complications.

RESULTS

Overall, emesis was experienced by 18% of patients in the post anesthesia care unit (PACU) and by 20% at home. Fifty percent of patients in the encouraged group versus 31% in the voluntary group reached the goal volume of oral liquids (p<0.05). The incidence of emesis was higher in both the encouraged (41% versus 14%) and voluntary group (40% versus 26%) when the goal volume of 240 ml was reached. There was no statistically significant difference between the two groups in terms of duration of PACU stay, incidence of emesis, number of episodes of emesis or volume of emesis. Further, there was no difference between the two groups in terms of post-operative complications including dehydration.

CONCLUSIONS

The current practice of a mandatory trial of oral fluid intake in the post-operative period may not be a necessary requirement for discharge. Further, mandatory oral fluids may result in a higher incidence of emesis.

The effect of bismuth subgallate as haemostatic agent in tonsillectomy

Tonsillectomy is one of the frequent operations performed by Otolaryngologists world over: Otolaryngologists are in search of a technique of tonsillectomy where the operation time and operative blood loss is less. This study was carried out to evaluate the effect of bismuth subgallate (BSG) and adrenaline on tonsillectomy time blood loss during the surgery as well as on the number of ties used. A prospective randomized trial of 60 patients was carried out, in which 30 had a tonsillectomy performed using BSG as haemostatic agent and in the remaining no heamostatic agent was used. Application of BSG in the tonsillar fossae reduces the operation time by 31.49%, the operative blood loss by 33.28% and also reduces the number of ties used by 53.33%. All these results are statistically significant.

Day stay pediatric tonsillectomy--a safe procedure

OBJECTIVE

There is a controversy about day stay pediatric tonsillectomy in the UK and Australia. New Zealand has a similar health structure and we wished to compare day stay tonsillectomy from our hospital with those reported from other centers.

METHODS

We performed a prospective audit of day stay tonsillectomy to determine conversion to hospital admission rate and the incidence of postoperative hemorrhage.

RESULTS

There were 4850 paediatric tonsillectomies performed with 80% of them as day stay procedures over a 9-year study period (1993-2002) in a university-affiliated tertiary children's hospital. The primary postoperative hemorrhage rate (within 24h of surgery) was 0.9% (CI 0.68-1.22%) and 83% occurred within the mandatory 4h postoperative observation period. Primary hemorrhage requiring re-operation to achieve hemostasis occurred in 18 children (0.37%, CI 0.2-0.54%). No child with a primary hemorrhage who presented after discharge following day stay surgery required re-operation or blood transfusion. Day stay surgery was planned in 4041 children and 4.7% (CI 4.1-5.4%) required conversion to hospital admission. Postoperative vomiting was the most common indication for conversion (2.65%, CI 2.2-3.1%), while hemorrhage contributed only 0.95% (CI 0.64-1.24%).

CONCLUSIONS

This study was performed in a health system similar to that of Australia and the UK. Complication and conversion rates are similar to those reported in North American centers. Pediatric day stay tonsillectomy is a safe procedure when performed with strict preoperative criteria, trained day stay unit (DSU) staff, and with in-patient facilities on site.

Anesthetic considerations for pediatric outpatient surgery

At least 60% of all pediatric surgical procedures are performed as outpatients. Successful outpatient practice requires that both the patients and the procedures are appropriate for outpatient management. Appropriate scheduling ensures that the overall function of the outpatient unit is not compromised. While not all scheduled patients need be perfectly healthy, care must be taken to provide adequate resources to those patients who are not, without diverting resources away from other patients. Anesthesia must be managed with attention to the unique physiologic and psychological challenges of children. Anesthetic management of postoperative nausea and vomiting and provision of adequate postoperative analgesia, including regional techniques, are important elements of the care plan.

Steroids and control of post-tonsillectomy pain

A prospective, randomized, double-blind study to assess the effect of steroids on post-tonsillectomy pain was performed on 82 adults. The premedication, anaesthesia, surgical technique and post-operative analgesia were standardized. Pain was assessed on a visual analog scale. Steroids were found to have no appreciable effect on the amount of post-operative pain.

Uso do subgalato de bismuto para hemostasia local em hepatectomias parciais em ratos

OBJETIVO: Avaliar os efeitos do subgalato de bismuto (SGB) usado na área cruenta pós-hepatectomia parcial, quanto a sangramento, aderências e estudo histológico. MÉTODO: Foram utilizados 30 ratos divididos em dois grupos iguais,submetidos à hepatectomias parciais com bisturi de lâmina. Para realizar a hemostasia no grupo 1 (G1), foi utilizado bisturi eletrônico e no grupo 2 (G2), SGB. No 7º dia de pós-operatório (PO), os animais foram mortos, e na cavidade abdominal foram observados sangramento, aderências e, a seguir, realizada a hepatectomia total englobando todos os tecidos adjacentes para análise histológica. No estudo histológico foram analisados: trombose da microcirculação, reação granulomatosa, necrose, fibrose, grau de inflamação e aderências. RESULTADOS: Não foi observado sangramento no PO nos dois grupos. No G1 estavam presentes aderências de omento ao fígado, consideradas neste trabalho como fisiológicas em 80% dos ratos, e no G2 estas aderências foram por outros órgãos, consideradas neste trabalho como anômalas em todos os casos. No exame histológico, quanto à reação granulomatosa e aderências, todos os ratos as apresentaram. Quanto à trombose e necrose o G1 apresentou maior intensidade. Quanto à fibrose e grau de inflamação os resultados foram semelhantes em ambos os grupos. CONCLUSÕES: Ambos os métodos são eficientes para prevenir hemorragia. O G2 apresentou aderências anômalas inviabilizando seu uso em humanos. O G1 revelou mais trombose e necrose. Quanto à reação granulomatosa, fibrose, grau de inflamação e aderências microscópicas, os resultados foram iguais nos dois grupos.

Effect of bismuth subgallate on nitric oxide and prostaglandin E2 production by macrophages

Bismuth subgallate (BSG) is used widely in clinics, including Vincent's angina, syphilis, and adenotonsillectomy. This study examined the effects of BSG on nitric oxide (NO) and prostaglandin E2 (PGE2) production in activated RAW 264.7 cells. BSG suppressed production of NO and PGE2 in a dose-dependent manner. BSG could increase TGF-beta1 production, which in turn might promote degradation of iNOS mRNA, thus inhibiting NO production. Additionally, BSG inhibited mPGES protein expression and COX-2 activity in activated RAW 264.7 cells. Exogenous addition of SNP reversed the inhibition effect of PGE2 production by BSG. This behavior indicates that PGE2 inhibition by BSG exerts an indirect effect through NO inhibition.

[Laser cordectomy without hospitalization. Is it a safe intervention?]

OBJECTIVE

To evaluate the safety of the CO2 Laser Cordectomy in the treatment of glottic carcinoma as a day-case procedure.

MATERIAL AND METHODS

Retrospective study of a cohort of 30 patients with glottic carcinoma treated with CO2 Laser Cordectomy at our institution between 1999-2001 as a day-case procedure.

RESULTS

There were no major complications and no patients required re-intubation. 90% of the patients were discharged the same day of the procedure. There were three unplanned admissions to the hospital but none of them were, in our opinion, the direct result of Cordectomy. These patients were discharged the next day. 100% of the patients answered that they would repeat the experience.

CONCLUSIONS

CO2 Laser Cordectomy of the glottic carcinoma can be safely performed as an outpatient procedure if patients are selected according to specific day-case criteria.

Estapedectomía como cirugía ambulatoria

Day case surgery is increasing and a large proportion of procedures in otolaryngology are already being performed as day cases. There is less experience in otologic surgery and the reports are specially referred to chronic otitis media. A retrospective study of stapedectomy as a day-case procedure is presented in this report. The inclusion criteria: anaesthesic risk: ASA I, II or III; if the patient has a chronic disease it must be well controlled; they must not have postoperative hemorrhagic history; the patient must be accompanied by an adult the first 24 hours postsurgery; must have a vehicle; distance to hospital must not be more than an hour and they must have a telephone. Between October 1998 and December 2002 71 ambulatory stapedectomies were performed in our institution. 91.2% were discharged home the same day of the procedure. Audiological findings obtained six months after surgery that: 87.5% of the patients have an air-bone Uda of 10 dB or less.

Assessment of secondary haemorrhage rates following adult tonsillectomy - a telephone survey and literature review

Many previous studies have considered patient re-admission rates alone as the true rate of secondary haemorrhage following adult tonsillectomy. We aimed to determine the true rate of secondary haemorrhage following tonsillectomy in adults by performing a telephone interview with 60 consecutive patients. Whilst 40% (n = 24) of our patients reported a significant episode of bleeding (blood actively flowing from their mouth for more than 1 min) following discharge, only 8% (n = 5) were re-admitted and only 3% (n = 2) required return to theatre. Review of the current literature suggests that return-to-theatre rates are more consistent than hospital re-admission rates in large studies. We would suggest that although secondary haemorrhage can occasionally be very serious, the majority is minor, and it would therefore be more useful when comparing different techniques for tonsillectomy to consider numbers of patients returning to theatre rather than re-admission rates.

Complications of adenotonsillectomy in children with OSAS younger than 2 years of age

The most common sleep disorder in children is obstructive sleep apnea syndrome (OSAS). The majority of children with OSAS improve following tonsillectomy and adenoidectomy (T&A). T&A as an outpatient procedure in children is very common. Young age in considered risk factors for postoperative respiratory complications. The purpose of this study is to analyze our experience with postoperative T&A complications in patients younger than 2 years of age. A total of 39 T&A were performed in children younger than 2 years of age. OSAS diagnosis was confirmed by overnight polysomnography (PSG). All the patients were hospitalized and monitored by overnight pulse oximetry monitoring. Post-operatively there was marked improvement in respiratory function in all the patients comparing pre- and post-operative nadir oxygen saturation (P<0.05). Complications were documented in seven patients (20%). Five of the complications occurred in children older than 1 year of age. Bleeding occurred in two patients (5.7%). Three patients (8.6%) had dehydration, one patient (2.9%) had hypercarbia and one patient had laryngospasm. In this study there was a low incidence of peri- and post- operative respiratory complications in children younger than 2 years of age who undergo T&A for OSAS. Identification of OSAS severity may be an important factor in determining the risk of T&A in a young child.

A retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications

OBJECTIVE

To retrospectively review the experience with tonsillectomy in the under 2-year-old child at an urban children's hospital.

METHODS

The medical records of 94 patients under 2 years old undergoing tonsillectomy between May 1, 1995, and May 31, 2000, were reviewed. The methods of tonsil and adenoid excision were noted, as was the use of perioperative steroids, antibiotics, and antiemetics. Outcome measures studied included the duration of postoperative inpatient observation, complications, time to first oral intake, prevalence of postoperative vomiting, type and duration of respiratory support, and improvement relative to operative indications.

RESULTS

Eighty-two patients (87%) underwent tonsillectomy and adenoidectomy (T&A). Twelve patients (13%) underwent tonsillectomy without adenoidectomy. Patient ages ranged from 12 to 23 months (mean 19.6+/-3.1). Indications included obstructive sleep apnea (OSA) in 51 patients (54%), chronic or recurrent tonsillitis in 30 (32%), both OSA and infection in 11 (12%), and acute tonsillitis with airway obstruction in two (2%). Comorbid conditions were numerous. Preoperative polysomnograms were obtained for eight patients (8%). Hospital stays ranged from 4 h to 16 days. Complications included hemorrhage in four patients (4%) and pneumonia in two (2%). Oxygen was required after discharge from the recovery room in 27 patients (29%), with seven more (7%) requiring either reintubation, continuous positive airway pressure, or nasopharyngeal airways. Of the 88 patients on oral diets, only five (5%) took longer than 24 h to resume oral intake. Two patients (2%) experienced significant emesis after surgery. Four patients (4%) required treatment for dehydration after discharge.

CONCLUSIONS

Tonsillectomy is a procedure with low morbidity in the otherwise healthy child under 2 years of age. However, we advocate routine postoperative overnight inpatient observation in this age group. We found that young children with comorbid conditions had a higher incidence of complications and required special postoperative management strategies.

Revisiting outpatient tonsillectomy in young children

OBJECTIVE

Postoperative same-day discharge is safe for most children undergoing tonsillectomy. However, young children with upper airway obstruction have a higher risk of postoperative complications. We review our tonsillectomy experience in children under 36 months to evaluate the safety of outpatient tonsillectomy in this population.

STUDY DESIGN AND SETTING

We conducted a retrospective study of all children under 36 months who underwent tonsillectomy during a recent 2-year period at The Children's Hospital of Philadelphia.

RESULTS

The indication for tonsillectomy in 96% of 421 children was upper airway obstruction. Eighteen percent required postoperative treatment to prevent respiratory compromise; 56% of these patients had no associated medical comorbidity. Patients younger than 24 months and those with medical comorbidities were more likely to require intervention.

CONCLUSION AND SIGNIFICANCE

It is not possible to preoperatively anticipate which children will have postsurgical complications. We recommend planning an overnight admission for children younger than 36 months undergoing tonsillectomy.

Post-tonsillectomy and -adenoidectomy hemorrhage in nonselected patients

This retrospective study was undertaken to evaluate the incidence of hemorrhage in nonselected patients requiring surgical treatment after adenoidectomy (group 1; 7,785 patients) or tonsillectomy with or without adenoidectomy (group 2; 6,794 patients). Postoperative bleeding from the tonsillar fossae occurred in 200 patients (2.94%). Primary hemorrhage (< 24 hours) clearly prevailed in groups 1 (86%) and 2 (78%). There was 1 case with a lethal outcome following tonsillectomy (0.007%). Bleeding from the epipharynx occurred in 17 patients of group 1 (0.21%). A total of 5 patients received blood transfusions, all of them belonging to group 2 (0.07%). The latest bleeding occurred 6 days (adenoidectomy) and 18 days (tonsillectomy) after surgery. Hemorrhage following both procedures is a rare complication predominantly occurring several hours after surgery and in nonselected patients. Male gender, age over 70 years, infectious mononucleosis, and a history of recurrent tonsillitis were found to be risk factors for posttonsillectomy hemorrhage.

The case for an outpatient "approach" for all pediatric tonsillectomies and/or adenoidectomies: a 4-year review of 1419 cases at a community hospital

OBJECTIVE

We sought to document the safety and efficacy of approaching all pediatric tonsillectomies and/or adenoidectomies (T/A) as outpatient procedures.

STUDY DESIGN AND SETTING

We conducted a 4-year retrospective study of 1419 pediatric patients undergoing T/A at an outpatient center with procedures performed by a single group of surgeons.

RESULTS

None of the 593 patients undergoing an adenoidectomy and only 5 (0.6%) of those having a tonsillectomy had significant bleeding postoperatively. There were no readmissions for airway problems. Children younger than age 3 were most likely to have complications and to be held for overnight observations.

CONCLUSIONS

Most children can be safely discharged after T/A. The higher incidence of perioperative complications in children who are younger than 3 years of age paralleled their higher rate of overnight observation.

SIGNIFICANCE

Children less than 3 years of age require more careful observation, especially after tonsillectomy and more likely will need to be observed overnight than older children.

Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome

OBJECTIVE

This technical report describes the procedures involved in developing the recommendations of the Subcommittee on Obstructive Sleep Apnea Syndrome in children. The group of primary interest for this report was otherwise healthy children older than 1 year who might have adenotonsillar hypertrophy or obesity as underlying risk factors of obstructive sleep apnea syndrome (OSAS). The goals of the committee were to enhance the primary care clinician's ability to recognize OSAS, identify the most appropriate procedure for diagnosis of OSAS, identify risks associated with pediatric OSAS, and evaluate management options for OSAS.

METHODS

A literature search was initially conducted for the years 1966-1999 and then updated to include 2000. The search was limited to English language literature concerning children older than 2 and younger than 18 years. Titles and abstracts were reviewed for relevance, and committee members reviewed in detail any possibly appropriate articles to determine eligibility for inclusion. Additional articles were obtained by a review of literature and committee members' files. Committee members compiled evidence tables and met to review and discuss the literature that was collected.

RESULTS

A total of 2115 titles were reviewed, of which 113 provided relevant original data for analysis. These articles were mainly case series and cross-sectional studies; overall, very few methodologically strong cohort studies or randomized, controlled trials concerning OSAS have been published. In addition, a minority of studies satisfactorily differentiated primary snoring from true OSAS. Reports of the prevalence of habitual snoring in children ranged from 3.2% to 12.1%, and estimates of OSAS ranged from 0.7% to 10.3%; these studies were too heterogeneous for data pooling. Children with sleep-disordered breathing are at increased risk for hyperactivity and learning problems. The combined odds ratio for neurobehavioral abnormalities in snoring children compared with controls is 2.93 (95% confidence interval: 2.23-3.83). A number of case series have documented decreased somatic growth in children with OSAS; right ventricular dysfunction and systemic hypertension also have been reported in children with OSAS. However, the risk growth and cardiovascular problems cannot be quantified from the published literature. Overnight polysomnography (PSG) is recognized as the gold standard for diagnosis of OSAS, and there are currently no satisfactory alternatives. The diagnostic accuracy of symptom questionnaires and other purely clinical approaches is low. Pulse oximetry appears to be specific but insensitive. Other methods, including audiotaping or videotaping and nap or home overnight PSG, remain investigational. Adenotonsillectomy is curative in 75% to 100% of children with OSAS, including those who are obese. Up to 27% of children undergoing adenotonsillectomy for OSAS have postoperative respiratory complications, but estimates are varied. Risk factors for persistent OSAS after adenotonsillectomy include continued snoring and a high apnea-hypopnea index on the preoperative PSG.

CONCLUSIONS

OSAS is common in children and is associated with significant sequelae. Overnight PSG is currently the only reliable diagnostic modality that can differentiate OSAS from primary snoring. However, the PSG criteria for OSAS have not been definitively validated, and it is not clear that primary snoring without PSG-defined OSAS is benign. Adenotonsillectomy is the first-line treatment for OSAS but requires careful postoperative monitoring because of the high risk of respiratory complications. Adenotonsillectomy is usually curative, but children with persistent snoring (and perhaps with severely abnormal preoperative PSG results) should have PSG repeated postoperatively.

Post-Tonsillectomy Hemorrhage: Results of a 3-Month Follow-Up

Episodes of post-tonsillectomy hemorrhage are unpredictable and potentially life-threatening. Primary post-tonsillectomy hemorrhage (<24 hr postoperatively) is generally considered to be more common and more serious than secondary hemorrhage (>24 hr). Therefore, recent studies have focused on the control of primary hemorrhage in order to determine the appropriate length of postoperative observation. The issue of follow-up is becoming more important in light of the increasing popularity of outpatient tonsillectomy. We undertook a prospective study to evaluate the incidence of post-tonsillectomy hemorrhage over the short and long term (3 mo). We studied 602 patients, aged 23 months to 89 years (mean: 20.6 yr), who had undergone inpatient tonsillectomy in 1999 and who had been hospitalized for at least 5 days. Our goal was to ascertain the number of episodes of postoperative hemorrhage that required surgical treatment under general anesthesia. We were able to contact 601 of these patients (or their parents) by telephone 3 months postoperatively to inquire about any instances of delayed secondary bleeding. In all, 16 patients (2.7%) had experienced post-tonsillectomy bleeding that required surgically achieved hemostasis under general anesthesia. Of this group, 11 patients (68.8%) had experienced primary hemorrhage and were treated immediately, and five (31.3%) experienced secondary hemorrhage. One patient in the latter group experienced excessive bleeding 38 days postoperatively, which we believe is the latest episode of secondary bleeding reported to date. Based on the findings of this study, we believe that a postoperative follow-up period of 10 days is sufficient to identify all but the most rare cases of post-tonsillectomy hemorrhage.

Prospective study of morbidity after tonsillectomy in children

Post-operative morbidity was prospectively studied in 384 children after tonsillectomy or adenotonsillectomy, using visual analogue scores to record symptom levels, and questionnaires to monitor satisfaction scores from the children and their families. Assessments were performed between the 7th and 14th day post-operatively. Two hundred children were assessed before the introduction of a pre-admission programme which consisted of an instructional videotape session in the ward and an advice booklet. Department practice was also changed to provide a bottle of paracetamol on discharge routinely for each child. Following these changes in practice a further 184 children were assessed. The provision of relatively simple measures in the programme increased parental satisfaction rates (P<0.05) and reduced GP contact rates (35--17%, P<0.05) post-operatively. The actual levels of morbidity were unchanged despite the provision of analgesia.

I.v. ketoprofen for analgesia after tonsillectomy: comparison of pre- and post-operative administration

We have evaluated the safety and efficacy of ketoprofen during tonsillectomy in 106 adults receiving standardized anaesthesia. Forty-one patients received ketoprofen 0.5 mg kg(-1) at induction ('pre' ketoprofen group) and 40 patients after surgery ('post' ketoprofen group), in both cases followed by a continuous ketoprofen infusion of 3 mg kg(-1) over 24 h; 25 patients received normal saline (placebo group). Oxycodone was used for rescue analgesia. Patients in the ketoprofen groups experienced less pain than those in the placebo group. There was no difference between the study groups in the proportion of patients who were given oxycodone during the first 4 h after surgery. However, during the next 20 h, significantly more patients in the placebo group (96%) received oxycodone compared with patients in the 'pre' ketoprofen group (66%) and the 'post' ketoprofen group (55%) (P=0.002). Patients in the placebo group received significantly more oxycodone doses than patients in the two ketoprofen groups (P=0.001). Two patients (5%) in the 'pre' ketoprofen group and one (3%) in the 'post' ketoprofen group had post-operative bleeding between 4 and 14 h. All three patients required electrocautery.

Laboratory tests in children undergoing ambulatory surgery: a review of clinical practice and scientific studies

The drive for cost containment in the United States has lead anesthesiologists to re-assess the benefits of routine pre-operative laboratory and radiological testing. The value of routine tests has been questioned not only by insurance companies but also by physicians. Common pre-operative laboratory and radiological tests are reviewed in the following analysis. Specifically, the use of such tests in children scheduled for ambulatory surgery is discussed. Current clinical practice patterns of pediatric anesthesiologists are included so that physicians may make conclusions on the basis of published literature and clinical practice of peers.

Bismuth subgallate-epinephrine paste in adenotonsillectomies

OBJECTIVE

To evaluate the role of bismuth subgallate-epinephrine (BSE) paste as a hemostatic in adenotonsillectomies.

DATA SOURCES

MEDLINE (January 1966-October 1999) and Current Contents (January 1997-October 1999) were searched, using bismuth subgallate, adenoidectomy, tonsillectomy, and adenotonsillectomy as search terms. A citation search was performed using Science Citation Index (January 1977-October 1999).

DATA SYNTHESIS

Adenotonsillectomies are common procedures; although there are few complications, hemorrhage is a concern. Bismuth subgallate has historically been used as an astringent and hemostatic. An evaluation of studies of bismuth subgallate and BSE paste was conducted.

CONCLUSIONS

There is minimal evidence to support this practice, but data suggest that epinephrine may be the active ingredient in BSE paste. BSE paste is inexpensive, poses little risk, and may decrease postoperative bleeding; therefore, it may be a reasonable hemostatic agent.

Early post-operative morbidity following tonsillectomy in children: implications for day surgery

Adenotonsillectomy and tonsillectomy are amongst the most commonly performed surgical procedures. In our prospective study we looked at early post-operative morbidity (haemorrhage, vomiting and pyrexia) in 521 consecutive children following tonsillectomy, adenotonsillectomy and adenoidectomy. While the incidence of reactionary haemorrhage is low, pyrexia and vomiting are common. The implications of this high early post-operative morbidity for day surgery are discussed.

Day case paediatric tonsillectomy: a review of three years experience in a dedicated day case unit

Tonsillectomy is one of the most common surgical procedures performed in children. Day case tonsillectomy is common in many parts of the USA but remains controversial in the UK. Day case tonsillectomy in children has been performed in a dedicated paediatric day care unit at the May day Hospital since 1994. The results for the years 1995-1997 were reviewed. In these years 928 true day case tonsillectomies were performed. Reactionary haemorrhage occurred in 0.97% (nine children) but only three children required a return to theatre. All bleeding occurred within the standard observation period. There were no deaths. The overall effective day case rate was 95.7%, only 31 children needing unplanned admission, mainly for postoperative vomiting. The results suggest that day case tonsillectomy can be safely and successfully performed, with a dedicated paediatric day case unit and a favourable population geography.

Adenotonsillectomy in the very young patient: cost analysis of two methods of postoperative care

Postoperative management of the patient younger than 36 months undergoing adenotonsillectomy has been the subject of many debates. Concerns for early postoperative complications such as airway obstruction, emesis, dehydration, and hemorrhage have led many physicians to consider overnight hospitalization following adenotonsillectomy in very young children. Trends in health care management have had increasing focus on cost effective means of treating patients to limit unnecessary expenditure on the part of the patient, physician, and hospital facility. The purpose of this retrospective review was to analyze two methods of early postoperative management in children less than 36 months old undergoing adenotonsillectomy at the Children's Hospital, San Diego from 1992 to 1997. Three hundred and seven cases were reviewed. Same-day discharge was compared with overnight inpatient observation based on the cost analysis of these two methods of postoperative care. Postoperative care was based on length of stay in the recovery room and as an inpatient. Expense of postoperative care was based on cost calculation for the recovery room and overnight hospitalization. Of the 307 patients, 194 went home the day of surgery and 113 were observed overnight in the hospital. Average hospital cost was higher in the outpatient group than in the inpatient group (P < 0.001). This difference reflects longer recovery room stay (350 min) in the outpatient group compared to the inpatient group (108 min) (P < 0.001). Outpatient adenotonsillectomy in the patient under 36 months may be safe; however, prolonged recovery room stays may actually make outpatient surgery less cost-effective than overnight admission. Recovery room costs are significantly higher per unit time than costs of inpatient hospitalization. Further investigation of cost-effective outpatient observation units may improve cost containment in the outpatient surgical setting.

Does bismuth subgallate have haemostatic effects in tonsillectomy?

Previous studies have shown that bismuth subgallate added to gauze swabs in tonsillectomy reduces the time to achieve haemostasis and probably reduces the risk of postoperative haemorrhage. All these studies have used bismuth subgallate in combination with adrenaline. In this randomised clinical study we investigated the effect of bismuth subgallate alone. A total of 204 patients were randomised into two groups. One hundred and six patients had swabs with bismuth subgallate. In the control group (n = 98), plain swabs were used. Operating time time to achieve haemostasis, peroperative blood loss, and incidence of postoperative haemorrhages were recorded. There were no significant differences between the two groups. We conclude that the evidence for using bismuth subgallate as a haemostatic agent in tonsillectomy is weak. The effect observed in previous studies can probably be ascribed to the effect of adrenaline.

Secondary tonsillectomy haemorrhage and non-steroidal anti-inflammatory drugs

Modern non-steroidal anti-inflammatory drugs (NSAIDs), are now widely accepted analgesics for post-tonsillectomy patients, but their effect on secondary haemorrhage has not been fully evaluated. This study attempts to evaluate the influence of NSAIDs on the secondary haemorrhage rate, and also whether mode of dissection is an important factor. The records of 557 consecutive patients undergoing tonsillectomy were studied to determine if there was a relationship between the secondary haemorrhage rate and discharge prescription of NSAIDs. There was an overall secondary haemorrhage rate of 5.2 per cent (29) and a significantly increased secondary haemorrhage rate in those taking regular NSAIDs, 11 per cent, compared to those not taking NSAIDs, 1.47 per cent, (chi 1(2) = 41.25, p < 0.001). There was a higher rate of secondary haemorrhages with bipolar dissection than with standard dissection for both those taking and not taking NSAIDs (13 per cent vs seven per cent and 2.75 per cent vs 0.87 per cent) however this was not statistically significant (chi 1(2) = 1.17, p = 0.19 and chi 1(2) = 0.773, p = 0.17). Both bipolar dissection and standard dissection individually showed very significant increases in secondary haemorrhage rate when on regular NSAIDs (chi 1(2) = 14.03, p = 0.004 and chi 1(2) = 6.19, p = 0.003). Although NSAIDs are very good analgesics, they may cause an increased secondary haemorrhage rate, and should be prescribed at discharge prescription with caution.

A prospective study of the length of stay of 150 children following tonsillectomy and/or adenoidectomy

This is a prospective study of the length of stay in 150 children who underwent adenoidectomy, tonsillectomy and adenotonsillectomy with and without grommets. Seventeen children were unsuitable for same-day discharge because of coexisting medical conditions and 39 because of social factors, which meant that 94 children were potentially suitable for same-day discharge. All patients received a standardized surgical and anaesthetic technique. Twenty-eight of the 94 children were kept in for postoperative complications thus 66 (70%) were treated as day cases. Haemorrhage occurred in one (1%); nausea and vomiting prevented discharge of 11 cases; and a further seven were kept overnight since the children were reluctant to eat and drink. Pain control was a problem with nine children (two had nausea and vomiting as well). Two patients had other complications. These results are compared to those found in the literature. Children who have adenoidectomy without tonsillectomy are more suitable for day surgery (P < 0.001). Because of the high risk of minor complications, the authors recommend that children who have tonsillectomy as part of the procedure should be treated from inpatient beds even when discharged on the same day.

Admission and discharge policy for paediatric adenoidectomy and tonsillectomy--a rural perspective

Adenoidectomy and tonsillectomy are amongst the most common surgical procedures carried out in children. We undertook a prospective audit in the Highlands of Scotland to document the views of general practitioners, parents, nursing staff and anaesthetists on admission and discharge policy. Of responses from 149 general practitioners, 119 (80 per cent) were in favour of change to same day admission and 22 (15 per cent) were not in favour. For change to same day discharge for adenoidectomy, 55 (37 per cent) were in favour and 81 (54 per cent) were not in favour. For change to next day discharge for tonsillectomy, the figures were 51 (34 per cent) and 89 (60 per cent) respectively. Responses from 14 trained paediatric nurses comprised 13 not in favour of same day admission, six in favour and seven not in favour of same day discharge for adenoidectomy and all 14 not in favour of same day discharge for tonsillectomy. All eight Consultant anaesthetists approached were happy with a change in policy to same day admission for children who were otherwise fit and well. Thirty-seven parents (70 per cent) preferred previous day admission and 14 (29 per cent) were happy with same day admission for their children. On the basis of these results, day-case adenoidectomy or tonsillectomy is not being considered in this area. Moves have been made, however, toward a policy of same day admission and next day discharge.

The effect of preoperative dexamethasone on the immediate and delayed postoperative morbidity in children undergoing adenotonsillectomy

In this prospective, randomized, double-blind, placebo-controlled study, we examined the effect of preoperative dexamethasone on postoperative nausea and vomiting (PONV) and 24-h recovery in children undergoing tonsillectomy. One hundred thirty children, 2-12 yr of age, ASA physical status I or II, completed the study. All children received oral midazolam 0.5-0.6 mg/kg preoperatively. Anesthesia was induced with halothane and nitrous oxide in 60% oxygen and maintained with nitrous oxide and isoflurane. Intubation was facilitated by mivacurium 0.2 mg/kg. Each child received fentanyl 1 microgram/kg i.v. before initiation of surgery, as well as dexamethasone 1 mg/kg (maximal dose 25 mg) (steroid group) or an equal volume of saline (control group). Intraoperative fluids were standardized to 25-30 mL/kg lactated Ringer's solution. All tonsillectomies were performed under the supervision of one attending surgeon using an electrodissection technique. Postoperatively, fentanyl and acetaminophen with codeine elixir were administered as needed for pain. Rescue antiemetics were administered when a child experienced two episodes of retching and/or vomiting. Before home discharge, the incidence of PONV, need for rescue antiemetics, quality or oral intake, and analgesic requirements did not differ between groups. However, during the 24 h after discharge, more patients in the control group experienced PONV (62% vs 24% in the steroid group) and complained of poor oral intake. Additionally, more children in the control group (8% vs 0% in the steroid group) returned to the hospital for the management of PONV and/or poor oral intake. The preoperative administration of dexamethasone significantly decreased the incidence of PONV over the 24 h after home discharge in these children.

IMPLICATIONS

In this double blind, placebo-controlled study, we examined the efficacy of a single large dose (1 mg/kg; maximal dose 25 mg) of preoperative dexamethasone on posttonsillectomy postoperative nausea and vomiting (PONV) in children 2-12 yr of age undergoing tonsillectomy. Compared with placebo, dexamethasone significantly decreased the incidence of PONV in the 24 h after discharge, improved oral intake, decreased the frequency of parental phone calls, and resulted in no hospital returns for the management of PONV and/or poor oral intake.

Complications of tonsillectomy and adenoidectomy

Adenotonsillectomy is generally safe surgery, but surgeons should be cognizant of potential complications and be prepared to manage them. Postoperative hemorrhage usually responds to local measures or cautery but can be life-threatening. Preoperative screening of coagulation profiles appears unnecessary. Anesthetic risks have declined with modern techniques, but airway risks, aspiration, and pulmonary edema are possible. Nasopharyngeal valving may be altered by velopharyngeal incompetence or nasopharyngeal stenosis. Sore throat, otalgia, fever, dehydration, and uvular edema are more common postoperative complaints. Less common complications include atlantoaxial subluxation, mandible condyle fracture, infection, eustachian tube injury, and psychological trauma. The prevalence, management, and strategies for avoidance of these are discussed.

Preoperative laboratory testing in children undergoing elective surgery: analysis of current practice

STUDY OBJECTIVE

To evaluate current practice in preoperative testing of healthy children undergoing elective surgery that is not expected to result in significant blood loss.

DESIGN

Survey of members of the Society for Pediatric Anesthesia.

SETTING

Anesthesiologists practicing in North America.

POPULATION

A total of 1,200 questionnaires were mailed.

INTERVENTIONS

Questionnaires were mailed to all members of the Society for Pediatric Anesthesia. All members were asked to specify which tests were routinely performed and to state why. Specific questions were asked about performing complete blood count (CBC), hemoglobin (Hb), hematocrit (Hct), and urine analysis (UA) in all patients, pregnancy test in adolescents, prothrombin time (PT) and activated partial thrombin time (PTT) prior to tonsillectomy, and sickle cell testing in black and/or Mediterranean children.

MEASUREMENTS AND MAIN RESULTS

685 of 1,200 (57%) questionnaires were returned. No attempt was made to identify and follow-up with nonresponders. Hb testing is routinely performed in 27% to 48% of the children depending on the age of the patient. UA is ordered preoperatively in less than 15% of the children. Pregnancy test was ordered by 43% of the respondents. Hemostatic tests prior to tonsillectomy were conducted by 45% of the anesthesiologists.

CONCLUSION

The results indicate the present practice of routine preoperative laboratory testing for children undergoing elective outpatient surgery. In spite of the many studies that indicate no specific benefits of performing routine preoperative testing in healthy children undergoing scheduled surgery, many physicians continue to order these tests in all such children.

The effects of an outpatient practice guideline at a teaching hospital: a prospective pilot study

Practice guidelines (PGs) are becoming increasingly important in modern medicine. To study the effects of a PG, we performed a pilot study at a large, urban, public teaching hospital according to a prospective, observational research design with both concurrent and historic controls. Specifically, we studied the effects of a multidisciplinary PG for pediatric outpatient tonsillectomy and adenoidectomy on the process of health-care delivery. Variables in the health-care process included patient compliance with clinic and surgery appointments, surgery time, operating room turnover, time in recovery room, unplanned admission rate, patient compliance with postoperative follow-up, provider compliance with guidelines, and hospital charges. Patients in the PG were found to have fewer preoperative laboratory tests, decreased duplication of services, and shorter operating room turnover times. Provider compliance with the PG varied by service and was intermittent at first but improved gradually. There was a trend toward improved compliance with postoperative follow-up in patients in the PG. Provider opinions concerning the guideline were positive. This pilot study demonstrates several advantages and disadvantages of the use of PGs in the outpatient setting and in a teaching hospital.