Day-case tonsillectomy in children: parental attitudes and consultation rates

Identifying barriers to obstructive sleep-disordered breathing care: Parental perspectives

OBJECTIVE

Despite established clinical practice guidelines for pediatric obstructive sleep-disordered breathing (SDB), disparities persist for this common condition. Few studies have investigated parental experiences about challenges faced in obtaining SDB evaluation and tonsillectomy for their children. To better understand parent-perceived barriers to treatment of childhood SDB, we administered a survey to assess parental knowledge of this condition.

MATERIALS & METHODS

A cross-sectional survey was designed to be completed by parents of children diagnosed with SDB. Two validated surveys were administered: 1) Barriers to Care Questionnaire and 2) Obstructive Sleep-Disordered Breathing and Adenotonsillectomy Knowledge Scale for Parents. Logistic regression modeling was performed to assess for predictors of parental barriers to SDB care and knowledge.

RESULTS

Eighty parents completed the survey. Mean patient age was 7.4 ± 4.6 years, and 48 (60%) patients were male. The survey response rate was 51%. Patient racial/ethnic categories included 48 (60.0%) non-Hispanic White, 18 (22.5%) non-Hispanic Black, and 14 (17.5%) Other. Parents reported challenges in the 'Pragmatic' domain, including appointment availability and cost of healthcare, as the most frequently described barrier to care. Adjusting for age, sex, race, and education, parents in the middle-income bracket ($26,500 - $79,500) had higher odds of reporting greater barriers to care than parents in the highest (>$79,500) income tier (OR 5.536, 95% CI 1.312-23.359, P = 0.020) and lowest income tier (<$26,500) (OR 3.920, 95% CI 1.096-14.020). Parents whose children had tonsillectomy (n = 40) answered only a mean 55.7% ± 13.3% of questions correctly on the knowledge scale.

CONCLUSION

Pragmatic challenges were the most encountered barrier that parents reported in accessing SDB care. Families in the middle-income tier experienced the greatest barriers to SDB care compared to lower and higher income families. In general, parental knowledge of SDB and tonsillectomy was relatively low. These findings represent potential areas of improvement to target interventions to promote equitable care for SDB.

Trajectory of Pain, Functional Limitation, and Parental Coping Resources Following Pediatric Short-stay Surgery: Factors Impacting Rate of Recovery

OBJECTIVES

Although there are many benefits of short-stay hospital admissions for high volume, pediatric surgical procedures, this model of care places greater responsibility on parents for the management of children's pain. This study aimed to document the trajectory of child pain outcomes and a range of parent-reported functional outcomes following discharge from a short-stay surgical admission. Moreover, we aimed to document the trajectory of parental perceived personal coping resources. Second, we assessed whether parental dispositional factors, assessed before hospital discharge, predicted the child's pain intensity and parent-reported functional recovery.

METHODS

Participants included children (aged 4 to 14 y) admitted for a short-stay tonsillectomy or appendectomy, and their parents. Parents completed a questionnaire before discharge from hospital. Demographic and surgical information was recorded from medical records. Following discharge, daily assessments of pain and functioning were carried out over a 10-day period using iPods or mobile phones. Predischarge and postdischarge data were obtained for 55 child and parent dyads.

RESULTS

Pain intensity scores returned to low levels (2/10 or less) by day 5 for appendectomy and day 10 for tonsillectomy. Parents' perceived personal coping resources increased more slowly following tonsillectomy than appendectomy. Controlling for time since surgery and parental coping resources, parental pain-related catastrophizing was a significant predictor of child pain and functional recovery.

DISCUSSION

Short-stay surgery results in parents facing considerable burden in managing their child's pain and functional impairment over a 10-day period. The potential value of screening for parental pain-related catastrophizing before discharge from hospital warrants further consideration and may enable identification of children likely to experience poorer recovery.

Peritonsillar infiltration of lidocaine with adrenaline is associated with increased risk of secondary post-tonsillectomy haemorrhage

OBJECTIVES

In order to evaluate the safety of tonsillectomy among children, we retrospectively studied the incidence of post-operative complications, adverse events and their association with peri-operative medication.

METHODS

Data were collected from the medical records of 691 patients aged 1-16 years, including details of post-operative complications (any unplanned contact with the hospital), analgesics, dexamethasone, 5-HT3 antagonists, local anaesthetic and haemostatic agents.

RESULTS

Recovery was complicated in 13.6 per cent of patients, of whom 8.4 per cent were re-admitted to the ward. The most common complication was post-tonsillectomy haemorrhage, experienced by 7.1 per cent of patients. Re-operation under general anaesthesia (for grade III post-tonsillectomy haemorrhage) was required by 4.2 per cent of patients. Peritonsillar infiltration of lidocaine with adrenaline increased the risk of post-tonsillectomy haemorrhage (odds ratio = 4.1; 95 per cent confidence interval = 2.1 to 8.3).

CONCLUSION

Every seventh paediatric patient experienced a complicated recovery after tonsillectomy, caused by post-tonsillectomy haemorrhage in most cases. Local peritonsillar infiltration of lidocaine with adrenaline was associated with an increased risk of post-tonsillectomy haemorrhage.

Preferred parental method of post-operative tonsillectomy and adenoidectomy follow-up (phone call vs. clinic visit)

INTRODUCTION

Tonsillectomy is the second most common procedure performed in the United States. Over 530,000 tonsillectomies are performed on children under 15 years of age in the United States, accounting for 16% of surgeries in this age group, resulting in missed school for patients of school-age and also resulting in missed work for caregivers. This study compared parent preferences for in-clinic follow-up (CFU) to telephone interview follow-up (TFU) after tonsillectomy.

MATERIALS AND METHODS

One hundred twenty-one parents of children who underwent a tonsillectomy and/or adenoidectomy were recruited to complete a survey about their child's post-operative visit.

RESULTS

Statistical analyses were performed using t-test, Wilcoxon rank-sum, and Fischer's exact tests where appropriate. 60.3% of the surveys were completed as a TFU and the remainder were completed as a CFU. There were no statistical differences in the children's age, the time to follow-up, satisfaction with their follow-up, or the frequency of unresolved symptoms. Of parents receiving TFU, 91.8% disagreed they would have preferred a CFU, with 86.3% strongly disagreeing, and only 5.5% expressing that they would have preferred a CFU. Of the parents with CFU, 47.9% expressed a preference for a TFU. For CFU, 43.9% of parents missed work and 58.1% of their school-age children missed school.

CONCLUSION

Our study results indicate that parents receiving phone follow-up strongly preferred this method to an in-clinic follow-up, and that nearly half of all parents receiving in-clinic follow-up would have preferred a telephone follow-up. In select patients, telephone follow-up after tonsillectomy may increase patient satisfaction and decrease days of missed work and school.

Is fasting duration important in post adenotonsillectomy feeding time?

Background:

Adenotonsillectomy is a common otolaryngology surgery. Nausea and vomiting are the most common complications of this procedure with a prevalence ranging from 49% to 73 %.

Objectives:

Our aim was to evaluate the effects of short time fasting protocol on decreasing postoperative pain, nausea and vomiting, and initiation of oral feeding after adenotonsillectomy.

Patients and Methods:

120 children aged 4 to 14 years candidates for adenotonsillectomy were randomly divided into intervention and control groups (n = 120, 60 in each group). Each patient of the intervention group was given oral dextrose 10% as much volume as he could consume at 3 and 6 hours prior to the operation. All the data including pain severity, nausea and vomiting of the patients, the time of oral feeding initiation etc. were gathered in checklists after the operation. Statistical analyses were then performed using Statistical Package for the Social Sciences (SPSS) software version 16. Descriptive statistical methods and mean difference test for independent groups and chi square test or Fisher exact test, and if regression needed model test were applied. A P value of 0.05 or less was considered statistically significant.

Results:

The amount of Acetaminophen administered for the intervention group was significantly lower than the control group, and also the time of oral feeding initiation was significantly shorter in the intervention group than the control group (P < 0.005). Pain severity at all occasions following surgery was significantly lower in the intervention group than the control group (P < 0.001). Although frequency of nausea at recovery time was significantly lower in the intervention group than the control group (P < 0.002), there were no significant differences in frequency of nausea between the two groups at other postoperative occasions. Postoperative vomiting frequency was not significant between the two groups at any occasions.

Conclusions:

The findings of this survey showed that shortening the duration of pre-adenotonsillectomy fasting period and hydration of patients several hours prior to the operation might be effective in decreasing postoperative pain and facilitating postoperative oral feeding initiation. Nevertheless this method does not seem to prevent postoperative nausea and vomiting.

Paediatric adenotonsillectomy as a daycase for obstructive sleep apnoea: how we do it in a tertiary unit

BACKGROUND

Paediatric adenotonsillectomy is a common ENT operation. Daycase surgery for uncomplicated, elective procedures is encouraged in order to improve efficiency in healthcare. For patients with obstructive sleep apnoea (OSA), most units advocate an overnight stay for adenotonsillectomy, a procedure usually performed as a daycase in other contexts.

METHODS

A retrospective casenote review was carried out from 1st December 2011 to 1st December 2012 for all children undergoing daycase adenotonsillectomy for treatment of OSA at Bart's Children's and the Royal London Hospital.

RESULTS

250 children underwent adenotonsillectomies for OSA as daycase procedures over twelve months. 6% had immediate, unplanned overnight admissions. 3% were readmitted within 30 days. No patients readmitted required surgical intervention.

CONCLUSION

For an appropriately selected child, adenotonsillectomy can be safely performed as a daycase procedure in a tertiary centre.

Postoperative pain, nausea and vomiting following adeno-tonsillectomy - a long-term follow-up

BACKGROUND

Adenotonsillectomy is a common pediatric surgical procedure. Our knowledge of the recovery profile, parental understanding, and expectations is limited. We aimed to assess the incidence of pain, nausea, and vomiting in children undergoing adenotonsillectomy on postoperative day 3 and 7. We also wished to evaluate parental understanding regarding discharge instructions as well as parental expectations and experience of their child's recovery.

METHODS

We enrolled 100 children (0-16 years) undergoing elective adenotonsillectomy. On day 3 and 7, parents were questioned about their child's level of pain, nausea/vomiting and their understanding regarding postoperative instructions.

RESULTS

Hundred children (median, 6.68 years) were recruited. 52% of parents rated their child's pain as VAS ≥ 5 on day 3, dropping to 30% by day 7. Almost 33% of patients experienced nausea on day 3, dropping to 11.6% by day 7. A similar trend was observed for postoperative vomiting. Most parents, 89%, agreed that postoperative instructions were clear. However, knowledge regarding when to seek emergency medical advice was found to be lacking. On day 7, only 44% of parents reported that their child's recovery met their expectations.

CONCLUSION

Adenotonsillectomy is associated with significant pain and PONV, persisting into the seventh postoperative day. Parental education and information seems inadequate and needs to be improved.

Risk factors for desaturation after tonsillectomy: analysis of 4092 consecutive pediatric cases

OBJECTIVES/HYPOTHESIS

To identify clinical risk factors for oxygen desaturation in the first 24 hours post-tonsillectomy, thus permitting the identification of those patients who warrant inpatient monitoring.

STUDY DESIGN

A retrospective analysis of 4092 consecutive patients undergoing tonsillectomy over a two-year period.

METHODS

Detailed clinical data were recorded for all patients who desaturated in the postoperative period (n = 294) and randomly selected controls (n = 368). Univariate and multivariate analysis was performed in order to identify independent risk factors for desaturation.

RESULTS

There were 294/4092 patients (7.2%) who experienced desaturations (defined as sustained saturations <90%) in the first 24 hours postoperatively (mean nadir, 78.7%). Multivariate analysis identified seven independent clinical risk factors for desaturation in the initial 24 hours post-tonsillectomy: trisomy 21, weight, coexistent cardiac disease, a coexistent syndromic diagnosis, a clinical diagnosis of obstructive sleep apnea (OSA), a coexistent neurologic diagnosis, and a prior diagnosis of pulmonary disease. A policy that admits all patients exhibiting any one of these risk factors except OSA would have identified 92% of the patients who subsequently desaturated. However, such a policy would also have required admission of 60% of the patients in our control group.

CONCLUSIONS

These findings are generally consistent with the Clinical Practice Guidelines recently published by the American Academy of Otolaryngology. In a tertiary care center, it may not be possible to identify an algorithm that admits all children at risk of desaturation while permitting the discharge of a high percentage of patients.

LEVEL OF EVIDENCE

3b.

Day-case tonsillectomy for children in Glasgow: the impact of changing indications and deprivation

Objective:

To determine the number of children undergoing tonsillectomy that could have this performed as a day surgery procedure.

Methods:

This paper reports a prospective cohort study, which entailed a comparison of children's eligibility for day-case surgery between 2001 and 2011 and an assessment of the Scottish Index of Multiple Deprivation scores.

Results:

In total, 148 children were enrolled. In 2011, 60 children (42 per cent) were eligible for surgery with same day discharge compared with 27 per cent in 2001. The percentage of children undergoing tonsillectomy for sleep-related breathing disorders or obstructive sleep apnoea hypopnoea syndrome increased from 26 per cent to 55 per cent.

Conclusion:

Eligibility for tonsillectomy with same day discharge has increased. This appears to be related to an increase in the number of children who are able to fulfil the social criteria for same day discharge. The results indicate an association between deprivation and tonsillectomy, particularly surgery carried out for the symptoms of sleep-related breathing disorders or obstructive sleep apnoea hypopnoea syndrome. There has been a significant increase in the percentage of children undergoing tonsillectomy for the indication of sleep-related breathing disorders or obstructive sleep apnoea hypopnoea syndrome.

Telephone follow-up for pediatric ambulatory surgery: parent and provider satisfaction

Traditional 4- to 6-week clinic follow-up after pediatric ambulatory surgery does not rapidly identify complications and is often a burden for parents. Telephone follow-up offers support and is preferred in a variety of adult populations, but there is little research in pediatrics to support this practice. This article describes a practice change involving a standardized telephone follow-up protocol by a pediatric nurse practitioner to parents within 1 week of their child's ambulatory surgery. An interview survey method was used to evaluate parent satisfaction with telephone follow-up and desire for a clinic visit. Staff satisfaction and resource utilization are also described.

Tonsil surgery efficiently relieves symptoms: analysis of 54 696 patients in the National Tonsil Surgery Register in Sweden

CONCLUSION

Patients operated with tonsillar surgery report a high degree of symptom relief 6 months after surgery.

OBJECTIVE

The purpose of this study was to analyze symptom relief 6 months after tonsil surgery in relation to age, indication, surgical procedure, primary bleeding and unplanned postoperative visits. The National Tonsil Surgery Register in Sweden offers data from 54,696 patients registered during 1997-2008.

METHODS

This was a prospective assessment by questionnaire. Data were collected using three questionnaires, two completed by professionals and one 6 months postoperatively by the parents/patients.

RESULTS

Among 54,696 patients, the most common surgical indications were obstruction (49.7%), followed by recurrent tonsillitis (35.2%). Symptom relief 6 months after surgery was high in all indication groups (>92%), and highest for patients operated on the indication peritonsillitis (>98%). The indications obstruction, recurrent tonsillitis or chronic tonsillitis reported a high degree (>96%) of symptom relief. Of the patients who underwent tonsillectomy with adenoidectomy, 97.5% were symptom-free compared to 96% of patients who had tonsillectomy alone and 96.1% who underwent tonsillotomy (p < 0.0001). In all, 13.9% of patients required an unplanned visit to the clinic postoperatively. Only 148 of 54,696 patients reported worsening of symptoms after surgery.

Paediatric day-case tonsillectomy: a three-year prospective audit spiral in a district hospital

BACKGROUND

Paediatric tonsillectomy is a common ENT operation. The use of day-case surgery is increasing, in order to improve efficiency in healthcare.

METHODS

A prospective audit spiral was carried out from January 2006 to December 2008 for all children undergoing day-case tonsillectomy at Huddersfield Royal Infirmary.

RESULTS

There was a haemorrhage rate of 2.6 per cent over three years. The most common complication was nausea and vomiting, seen in 5.3 per cent of patients.

CONCLUSIONS

For a well selected group of children, day-case tonsillectomy in a district hospital setting is a safe and efficient alternative to an in-patient stay. A dedicated day-case team, good anaesthetic technique, adequate post-operative analgesia and on-site paediatric in-patient facilities are essential.

A randomised controlled trial of two analgesic techniques for paediatric tonsillectomy*

Investigators from Bristol described a fentanyl- and diclofenac-based analgesic technique for tonsillectomy with low postoperative nausea and vomiting rates and low pain scores. This study compared the effectiveness of a modified Bristol technique with a codeine-based regimen with respect to PONV and analgesia. Sixty-five children, ASA 1-2, were randomly assigned to either the Bristol group (fentanyl 1-2 μg.kg(-1) and diclofenac 1-2 mg.kg(-1)) or codeine group (codeine 1.5 mg.kg(-1)). All children received paracetamol 15 mg.kg(-1) and dexamethasone 0.1 mg.kg(-1) . Postoperative nausea and vomiting and pain scores were recorded hourly, and fitness for discharge was assessed at 4 h. The overall incidence of postoperative nausea and vomiting was 21% with no difference between groups (Bristol group 8/30, codeine group 5/32, p = 0.29). Children in the Bristol group required analgesia earlier than those in the codeine group (p < 0.005), but maximum pain scores were not different (Bristol group median (IQR [range) 4.5 (3-5 [0-5]), codeine group 4.0 (2-5 [1-5]), p = 0.15). Twenty-three per cent of children were assessed as not fit for discharge at 4 h. The codeine-based regimen may have a small advantage over the Bristol regimen, but neither technique seems ideally suited for a day-case service without a longer period of observation. You can respond to this article at http://www.anaesthesiacorrespondence.com.

Perioperative acupuncture and postoperative acupressure can prevent postoperative vomiting following paediatric tonsillectomy or adenoidectomy: a pragmatic randomised controlled trial

OBJECTIVE

To investigate the effectiveness of acupuncture and acupressure as supplements to standard treatment for postoperative vomiting in children undergoing tonsillectomy and/or adenoidectomy.

METHODS

A pragmatic, open, block-randomised controlled trial. The results were analysed according to the intention-to-treat principle. The study was conducted without extra resources in a normal setting at the day-surgery department of Lovisenberg Diakonale Hospital in Oslo. 154 children with an American Society of Anesthesiologists grade 1-2, weighing at least 10 kg, were included. Children with concomitant gastrointestinal diseases, emesis or antiemetic treatment <24 h preoperatively, rash or local infection over the actual acupuncture points were excluded together with patients whose parents' informed consent could not be obtained. The intervention group received acupuncture at pericardium 6 bilaterally, at a depth of approximately 0.7 cm with a median of 21 min during anaesthesia, followed by acupressure wristbands for 24 h and standard treatment. The control group received standard treatment. The primary end point was the occurrence of vomiting or retching during 24 h postoperatively.

RESULTS

Children in the acustimulation group experienced less retching and vomiting than the control group-46.8% versus 66.2% (p=0.015). The effect of acustimulation was specifically pronounced in girls and children aged 1-3 years.

CONCLUSION

This trial indicates the effectiveness of acustimulation as an adjunct to standard treatment. The results should encourage and promote the implementation of acustimulation for postoperative vomiting in children undergoing adenoidectomy or tonsillectomy.

Challenges in pediatric ambulatory anesthesia: kids are different

The care of the child having ambulatory surgery presents a specific set of challenges to the anesthesia provider. This review focuses on areas of clinical distinction that support the additional attention children often require, and on clinical controversies that require providers to have up-to-date information to guide practice and address parental concerns. These include perioperative risk; obstructive sleep apnea; obesity; postoperative nausea and vomiting; neurocognitive outcomes; and specific concerns regarding common ear, nose, and throat procedures.

Children's tonsillectomy experiences: influencing factors

The aim of this study was to explore factors influencing children's (7-13 years) tonsillectomy experiences and outcomes. A prospective, repeated measures, design was used to investigate the effect of age, gender, ethnicity, time, and previous pain, hospitalization and surgery on children's (N = 60) perceptions of anxiety, pain intensity, quality of pain and sleep, and oral intake. The relationship between postoperative pain and anxiety was also examined. Using a diary, three days of data were collected. Descriptive statistics, Pearson correlation coefficient, and a mixed linear regression model were used for analysis. Children's tonsillectomy experiences and outcomes were affected by time, previous experience, age, and anxiety. Moderate correlations were found between level of anxiety and pain intensity. These findings provide clinicians with additional knowledge to guide their perioperative practice and care of children.

The effect of preoperative fasting on postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy

OBJECTIVE

The aim of this prospective randomized study was to examine whether active counseling and more liberal oral fluid intake decrease postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy.

METHODS

Families, whose child was admitted for ambulatory tonsillectomy or adenotonsillectomy, were randomly assigned to the study groups (n=116; 58 families in each group). The intervention group received the fasting instructions with face-to-face counseling for the child's active preoperative nutrition, and the control group the fasting instructions according to the hospital's standard procedure. The level of postoperative pain and nausea was scored in the postanesthesia care unit (PACU) during the first postoperative hour, as well as at 2, 4, 8 and 24h postoperatively. The first scoring in PACU was performed by the attending nurse with a 0-10 scale. The rest of the estimations were made independently and simultaneously by the children using a VAS scale, and by the parents using a 0-10 scale.

RESULTS

The children in the control group were in more pain in the PACU than the children in the intervention group, and the difference between the groups was statistically significant (p=0.0002). All pain scores, according to the children and the parents, increased after the surgery. In both groups the highest score values were found at home 8h after surgery, and no significant difference was found between the study groups. On the first postoperative morning, the children in the control group were in pain (p=0.047). The children did not have significant nausea in the PACU, but the nausea increased postoperatively. Four hours after surgery the children were most nauseous according to all estimations (60%, n=116). More than half of the children vomited and most vomited clotted blood. Nausea and vomiting decreased during the evening of the surgery, but six children vomited the next morning, four of them vomited blood. The incidence and intensity of postoperative nausea and vomiting between the intervention and control groups were not statistically significant. However, preoperative nutritional counseling and more liberal per oral fluid intake appeared to have a positive effect on the children's well-being and helped them to better tolerate postoperative nausea and vomiting.

CONCLUSIONS

The preoperative counseling about active preoperative nutrition significantly reduces the child's pain during the first posttonsillectomy hours and might prepare the child to better tolerate the stress of potential postoperative nausea and vomiting.

Ear, nose and throat day-case surgery at a district general hospital

INTRODUCTION

In 2000, The NHS Plan in the UK set a target of 75% for all surgical activity to be performed as day-cases. We aim to assess day-case turnover for ENT procedures and, in particular, day-case rates for adult and paediatric otological procedures together with re-admissions within 72 h as a proxy measure of safety.

PATIENTS AND METHODS

Retrospective collection of data (procedure and length of stay) from the computerised theatre system (Galaxy) and Patient Information Management System (PIMS) of all elective patients operated over one calendar year. The setting was a district general hospital ENT department in South East England. All ENT operations are performed with the exception of oncological head and neck procedures and complex skull-base surgery.

RESULTS

Overall, 2538 elective operations were performed during the study period. A total of 1535 elective adult procedures were performed with 74% (1137 of 1535) performed as day-cases. Of 1003 paediatric operations, 73% (730 of 1003) were day-cases. Concerning otological procedures, 93.4% (311 of 333) of paediatric procedures were day-cases. For adults, we divided the procedures into major and minor, achieving day-case rates of 88% (93 of 101) and 91% (85 of 93), respectively. The overall day-case rate for otological procedures was 91% (528 of 580). Re-admission rates overall were 0.7% (11 of 1535) for adults and 0.9% (9 of 1003) for paediatric procedures. The most common procedure for re-admission was tonsillectomy accounting for 56% of all adult re-admissions and 78% of paediatric re-admissions. The were no deaths following day-case procedures.

DISCUSSION

ENT surgery is well-suited to a day-case approach. UK Government targets are attainable when considering routine ENT surgery. Day-case rates for otology in excess of targets are possible even when considering major ear surgery.

Children's pre-operative tonsillectomy pain education: clinical outcomes

OBJECTIVE

To examine the effects of pre-operative tonsillectomy pain education on children's (7-13 years) self-reported pre-operative anxiety and post-operative clinical outcomes (i.e., anxiety, pain intensity, quality of pain and sleep, oral intake, perceptions of pre-operative education, and pain expectation).

METHOD

A prospective, repeated measures, quasi-experimental design using an age appropriate pain education booklet (n = 30) and a standard care comparison group (n = 30) was employed to investigate children's pre- and post-education anxiety and post-operative tonsillectomy with or without adenoidectomy subjective experiences in the hospital and home settings. Group comparisons were performed using the Wilcoxon test, Fisher's exact test, repeated measures analysis of variance, and mixed model regression.

RESULTS

There were no significant differences between groups for measures of anxiety, pain intensity, quality of pain and sleep, oral intake, or expected pain. There was no change in anxiety before or after pre-operative education (P = 0.85). Ninety-six percent (n = 25) of the children in the intervention group reported that pre-operative pain education helped with their post-operative pain and 72% (n = 16) in the control group stated that it would be helpful to learn about pain before surgery. The majority of children in both the intervention and control groups (96%, 91%, respectively) stated learning about the 0-10 numeric pain intensity scale helped or would be helpful to learn pre-operatively.

CONCLUSION

Pre-operative pain education did not affect anxiety. Children valued pre-operative pain education. Pre-operative pain education may influence children's perceptions of medical care.

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.

Follow-up Phone Calls After Pediatric Ambulatory Surgery for Tonsillectomy: What Can We Learn From Families?

The purpose of this quality improvement study was to describe families' responses regarding the adequacy of the preoperative preparation provided in the Preoperative Assessment Clinic, and the necessity of two follow-up phone calls after pediatric ambulatory surgery for tonsillectomy with or without adenoidectomy (T+/-A). Using a questionnaire developed for the study, 90 families were contacted by phone on the first postoperative day and, of them, 73 were contacted a second time between the ninth and twelfth postoperative days. Families' responses were reported in four categories: (1) concerns, (2) use of resources, (3) adequacy of the preoperative teaching, and (4) necessity of the two postoperative phone calls. Results showed that, at the first phone call, a sore throat was reported as the most important concern followed by a decreased oral intake (ie, fluid, food, medicine), vomiting, and fever or "perceived fever." During the second phone call, a sore throat remained the most important concern followed by a decreased intake. Earache was the third highest concern and vomiting was then reported of concern by a minority of families. The most frequently consulted resource person for concerns was the physician on call for the otolaryngology service. Eighty-seven percent of families felt the preoperative preparation was adequate. For reasons of instructional and/or emotional support, 94% of families who responded reported that the first phone call was necessary and 68% reported that the second call was as well.

A snapshot of children's postoperative tonsillectomy outcomes at home

PURPOSE

To describe home outcomes of pain, medication use, fluid intake, and emesis 24 hr after tonsillectomy and adenoidectomy. The theory of unpleasant symptoms provided a conceptualizing framework.

DESIGN AND METHODS

A secondary analysis was conducted. Outcomes for 76 children were recorded on a home diary that included: self-reported pain, analgesic use, fluids ingested, and emesis. Descriptive and inferential statistics were used.

RESULTS

Children reported moderate pain. Children who received analgesics received less than recommended standards. Only 11% of the children drank the recommended fluids, and 31% of the children vomited at home.

PRACTICE IMPLICATIONS

Parents need to become partners in pain management. Recommend multimodal discharge teaching and follow-up phone call at home to ensure adequate analgesic administration and fluid intake.

Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis

Postoperative vomiting (POV) remains one of the commonest causes of significant morbidity after tonsillectomy in children. A variety of prophylactic anti-emetic interventions have been reported, but there has only been a limited systematic review in this patient group. A systematic search was performed by using Cochrane Controlled Trials Register, MEDLINE and EMBASE to identify double-blind, randomized, placebo-controlled trials of prophylactic anti-emetic interventions in children undergoing tonsillectomy, with or without adenoidectomy. The outcome of interest was POV in the first 24 h. Summary estimates of the effect of each prophylactic anti-emetic strategy were derived using fixed effect meta-analysis. Where appropriate, dose-response effects were estimated using logistic regression and 22 articles were identified. Good evidence was found for the prophylactic anti-emetic effect of dexamethasone [odds ratio (OR) 0.23, 95% CI 0.16-0.33], and the serotinergic antagonists ondansetron (OR 0.36, 95% CI 0.29-0.46), granisetron (OR 0.11, 95% CI 0.06-0.19), tropisetron (OR 0.15, 95% CI 0.06-0.35) and dolasetron (OR 0.25, 95% CI 0.1-0.59). Metoclopramide was also found to be efficacious (OR 0.51, 95% CI 0.34-0.77). There is not sufficient evidence to suggest that dimenhydrinate, perphenazine or droperidol, in the doses studied, are efficacious, nor were gastric aspiration or acupuncture. In conclusion, dexamethasone and the anti-serotinergic agents appear to be the most effective agents for the prophylaxis for POV in children undergoing tonsillectomy.

Outpatient tonsillectomy in children: a systematic review

OBJECTIVE

To evaluate the level of evidence regarding the safety of outpatient pediatric tonsillectomy.

STUDY DESIGN AND SETTING

The medical literature addressing outpatient pediatric tonsillectomy was systematically reviewed. The level of evidence was assessed, and data were pooled.

RESULTS

Seventeen articles met inclusion criteria. Each article suggested that outpatient tonsillectomy was safe. The overall level of evidence was fair (grade B-). Pooled data analysis in the perioperative period showed a complication rate estimate of 8.8% (95% confidence interval [CI], 5.5%-12.1%; P < or = 0.001) and an unplanned admission rate estimate of 8.0% (95% CI, 5.3%-10.7%; P < or = 0.001). Subgroup analysis suggests that children under age 4 are at a higher risk of complications in the perioperative period with an odds ratio of 1.64 (95% CI, 1.16-2.31).

CONCLUSION

The level of evidence supporting the safety of outpatient pediatric tonsillectomy is fair. The analyzed data show a higher rate of early complications and unplanned admissions in children under age 4.

SIGNIFICANCE

The current evidence supports the practice of outpatient tonsillectomy in properly selected children.

EBM RATING

A-1a.

Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy

More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.

Patients’ preferences for length of stay: valuable in day-case tonsillectomy planning

Day-case tonsillectomy is becoming more common, but patient satisfaction varies. Before beginning day-case tonsillectomies, we evaluated patients' wishes as to optimal discharge timing. We conducted a prospective study of all 294 patients undergoing elective tonsillectomy or adenotonsillectomy at a tertiary care clinic for 1 year. At discharge, patients received a questionnaire on their preferred length of stay. Of the 236 (80.3%) patients returning the questionnaire, 94 (39.8%) preferred discharge on the 1st, 141 (59.7%) on the 2nd postoperative day or later, and only one patient (0.4%) would have wished day-case tonsillectomy. Patients with postoperative fever, older patients and those discharged on the 2nd postoperative day or later were more likely to prefer a longer postoperative stay. Patients rejected the idea of day-case tonsillectomy after in-patient operation. Day-case tonsillectomies should be begun only after careful preparation of the staff, in children, and preferably in a day-surgery unit.

Evaluation of tissue-specific promoters in carcinomas of the cervix uteri

BACKGROUND

Gene therapy is a novel approach for treatment of patients with advanced, recurrent, or metastatic cervical cancer. One effective way to direct transgene expression to specific tissues or tumors is the use of tissue-specific-promoters (TSPs). In the context of adenovirus (Ad)-mediated cancer gene therapy it is rational to choose a TSP which is highly expressed in the tumor but has potentially low activity in non-tumor cells, especially the liver. In this study, we have investigated several promoters which fulfill these criteria. Candidate cervical cancer specific TSPs include promoters of the genes for secretory leukoprotease inhibitor (SLPI), cyclooxygenase-2 (COX-2), Midkine (MK), vascular endothelial growth factor receptor type 1 (flt-1), vascular endothelial growth factor (VEGF), Survivin and the receptor for chemokine SDS-1 (CXCR4).

METHODS

To evaluate the specific gene expression of the different promoters in the context of cervical cancer, we constructed a panel of E1-deleted Ads that express luciferase under the control of the promoters of interest. We investigated various established cervical cancer cell lines, as well as purified primary cancer cells and normal control cells from the cervix uteri.

RESULTS

In all cell lines tested, promoters for MK, VEGF and CXCR4 showed the highest activity. Both MK and VEGF promoters also resulted in a high activity in primary cervical cancer cells. Interestingly, gene expression profiles correlate with luciferase activity in both cell lines and primary cancer samples.

CONCLUSIONS

Our study demonstrates that the promoters for MK and VEGF are active in cervical cancer. We believe that both promoters can be successfully employed as TSPs for gene therapy targeted to cervical cancer.