Outpatient tonsillectomy in children: a 7-year experience

OBJECTIVES

To report our centre's experience of outpatient tonsillectomy in children over a 7-year period and to evaluate the postoperative complication rate in this type of procedure compared to tonsillectomy performed in the context of conventional hospitalisation.

MATERIAL AND METHODS

Retrospective review of medical charts.

RESULTS

From May 2002 to April 2009, 276 tonsillectomies were performed on an outpatient basis, i.e. 55.4% of all paediatric tonsillectomies, in children with a mean age of 5.28 years. Ninety-six children (34.8%) presented clinical OSAS. Development of an early postoperative complication (before H8) required conventional hospitalisation on D0 in six (2.1%) of these 276 children operated on an outpatient basis: early postoperative bleeding in four cases (1.4%), which required reoperation to control bleeding in three cases, refusal to feed in one case (0.3%), and a parental problem in one case (0.3%). Postoperative complications occurring after H8 required readmission in six cases (2.1%): pain and feeding difficulties in two cases (0.7%) on D1 and D5, respectively, bleeding in four cases (1.4%) with reoperation before H24 for one patient, D5 for two patients and D7 for one patient. Only one case of bleeding occurred between H8 and H24. No perioperative respiratory complications were observed in children with clinical OSAS.

CONCLUSION

The results of this study show that, in line with international publications and meta-analyses, post-tonsillectomy complications between H8 and H24 postoperatively, mainly bleeding, are exceptional. Respiratory complications usually occur in high-risk clinical settings that are not eligible for outpatient surgery. Outpatient tonsillectomy is therefore a safe procedure in children presenting all of the required medical, social and organizational conditions.

[Patient evaluation of the quality of anesthesia management]

A questionnaire completed by 90 adults after ENT or stomatological surgery showed that most of them were anxious preoperatively, mainly because of anaesthesia and that a "personalized" preanaesthetic examination was the most efficient means to decrease it. Although a majority of them was satisfied with the anaesthetic care, anaesthetic morbidity remains important. The personalization of pre, per and postanaesthetic management by the same anaesthetist is probably the best means for improving the quality of care.

Complications and fiberoptic assessment of size 1 laryngeal mask airway

In pediatric practice, complications due to the laryngeal mask airway (LMA) have been studied with size 2 LMA, but not with size 1 LMA. We, therefore, compared prospectively the complications induced by LMA size 1 and 2 in 141 children aged 21 days to 11 yr. Intraoperative and lowest SpO2 values after removal of LMA were recorded. The following complications were recorded: cough, laryngospasm, bronchospasm, apnea, and airway obstruction. In 14 patients in the size 1 LMA group and 26 patients in the size 2 LMA group, pharyngolaryngeal structures were checked with fiberoptic examination. The number of attempts, complications, intraoperative SpO2, and lowest SpO2 values were similar when using size 1 and size 2 LMA. Fiberoptic examination of size 1 LMA showed a high incidence of impinging of the epiglottis in the LMA bars without airway obstruction. In conclusion, there was no difference in the complication rate between the two pediatric sizes of LMA when used in pediatric patients.

Ventilatory response to carbon dioxide after epidural clonidine injection

The authors studied the effects of epidural clonidine (300 micrograms) on circulation and ventilatory control in seven healthy unpremedicated subjects. After clonidine injection, arterial blood pressure decreased significantly in all subjects (range, 13%-25% for systolic blood pressure and 13%-32% for diastolic blood pressure). Heart rate decreased significantly by 10%-16% between 75 and 105 min after injection. The slope of the ventilatory response to CO2 decreased significantly from 2.06 +/- 0.70 (baseline) to 1.37 +/- 0.68, 1.25 +/- 0.65, and 1.33 +/- 0.67 L.min-1.mm Hg-1 (mean +/- SD, P less than 0.05) at 15, 60, and 120 min. The authors conclude that epidural clonidine induces mild ventilatory and circulatory depression.

Analgesia and ventilatory response to carbon dioxide after intramuscular and epidural alfentanil

The analgesic and ventilatory depressant effects of epidural and intramuscular alfentanil (15 micrograms/kg) were compared in two groups of seven healthy unpremedicated subjects. Fifteen minutes after IM injection, the slope of the ventilatory response to CO2 decreased significantly (from 2.72 +/- 0.34 to 1.8 +/- 0.20 L.min-1.mmHg-1) while assessment of periosteal analgesia showed no change. After epidural injection, the slope of the ventilatory response to CO2 decreased significantly (from 2.32 +/- 0.42 to 1.61 +/- 0.29, 1.51 +/- 0.29, and 1.53 +/- 0.21 L.min-1.mm Hg-1) at 15, 45, and 90 minutes (x +/- SD, P less than 0.05), and there was significant periosteal analgesia of the tibia (15 and 30 minutes after injection) and of the radius (30 to 90 minutes after injection). Throughout the study, plasma alfentanil levels were similar after intramuscular and epidural injection. These results suggest that epidural alfentanil induces ventilatory depression due to the rostral spread of the drug rather than to systemic absorption.

Ventilatory response to carbon dioxide after intramuscular and epidural fentanyl

The authors compared the effects of administration of fentanyl 200 micrograms on the ventilatory response to carbon dioxide in two groups of nine healthy unpremedicated subjects: one group received fentanyl as an intramuscular injection; in the other group, fentanyl was injected into the epidural space. In the intramuscular group, the slope of the ventilatory response to CO2 did not decrease significantly. In the epidural group, the slope of the ventilatory response to CO2 decreased significantly from 2.48 +/- 1.05 to 1.77 +/- 0.7, 1.74 +/- 0.7, and 2.07 +/- 0.74 L X min-1 X mm Hg-1 at 30, 60, and 120 min after injection (chi +/- SD, P less than or equal to 0.05), respectively. At each time of the study, plasma fentanyl levels were significantly lower in the epidural group than in the intramuscular group (P less than or equal to 0.05). These results suggest that epidural fentanyl induces a nonsystemic ventilatory depression that may be due to the rostral spread of the drug.