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Moderator: Dr. Anjolie Presenters: Dr. Senthil Dr. Dipal

Moderator: Dr. Anjolie Presenters: Dr. Senthil Dr. Dipal. Adenotonsillectomy & OSA. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Indications:. Chronic/ recurrent tonsillitis Adenotonsillar hyperplasia with OSA Tonsillar hyperplasia Peritonsillar abscess

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Moderator: Dr. Anjolie Presenters: Dr. Senthil Dr. Dipal

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  1. Moderator: Dr. AnjoliePresenters: Dr. Senthil Dr. Dipal Adenotonsillectomy & OSA www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Indications: Chronic/ recurrent tonsillitis Adenotonsillar hyperplasia with OSA Tonsillar hyperplasia Peritonsillar abscess Streptococcal carriage with valvular heart disease Adenoiditis Recurrent/ chronic rhino sinusitis/Otitis media

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

  4. Contraindications: Systemic infection Uncorrected coagulopathy Occult/ frank cleft palate Bifid uvula: clue to occult cleft palate Sx: hypernasal speech, velopharyngeal incompetence Adenoidectomy: partial

  5. History: Infection Obstructive sleep apnea Bleeding tendencies, sickle cell disease Use of Acetylsalicylic acid ingestion: defer for 10 days…

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

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

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

  9. Tonsil size: Classification of tonsil size, including percentage of oropharyngeal area occupied by hypertrophied tonsils Barash,5th edition …

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

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

  12. Monitoring: SPO2 ETCO2 Precordial stetho ECG Temp BP PAP Blood loss Appropriate size i.v. catheter

  13. Airway management Intravenous/ inhalational Preformed RAE ETT cuffed0.5-1 cm smaller size Oral packing: uncuffed tube Armoured LMA Midline fixation Brown- Davis mouth gag

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

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

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

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

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

  19. Pain management: NSAIDS Opioids Local infiltration TENS

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

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

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

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

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

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

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

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

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

  29. American Academy Of Otolaryngology Head & Neck Surgery Pediatric Otolaryngology Committee Age ≤3 yr Abnormal coagulation with/without identified bleeding disorder in patient/family Evidence of OSA/apnea Craniofacial/ other airway abnormalities, syndrome disorders: choanal atresia & laryngotracheal stenosis Barash 5th edition

  30. American Academy Of Otolaryngology Head & Neck Surgery Pediatric Otolaryngology Committee Systemic disorders: preop cardiopulmonary, metabolic/ general medical risk Procedure done: acute peritonsillar abscess Extended travel time, weather conditions & home social conditions not consistent with close observation, cooperation & ability to return to the hospital quickly

  31. Post tonsillectomy bleeding: 1ºh’gge: < 24hrs, generally < 6 hrs More brisk, fatal, profuse, slipping of ligatures 2ºh’gge: 24hrs – 5/6 days post op Eschar on tonsillar bed sloughs Measures: Post nasal pack Re-exploration

  32. Re-exploration: O.1%incidence of re-exploration Mortality: 1:14000 Issues: Bleeding and Hypovolemia Difficult airway Aspiration

  33. Bleeding: Signs and symptoms of hypovolemia: mild- severe Large bore i.v. access Correction: colloids and crystalloids Difficult to estimate blood loss: adrenergic drive, swallowing of blood HCT measurement

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

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

  36. OSA Def: recurrent episodes of partial/ complete obstruction of upper airways during sleep resulting in disruption of normal ventilation & sleep patterns. 2% prevalence Peak: 2-8 yrs Level of obstruction: soft palate & base of tongue

  37. Pathophysiology: Anatomical: upper airway narrowing: adenotonsillar hypertrophy, craniofacial anomalies Obesity: strongest predictor Neuromotor factors: reduced central mediated activation of upper airway muscles, neuromuscular diseases

  38. Clinical features: Daytime: Mouth breathing Poor school performance Daytime somnolence Morning headaches Fatigue Hyperactivity Aggression Social withdrawal • Nocturnal: • Snoring • Labored • breathing • Paradoxical • respiratory • effort • Apnea • Sweating • Unusual sleep • positions • Enuresis

  39. Complications: Growth impairment: failure to thrive PHT, cor-pulmonale, heart failure BP dysregulation Each apneic episode-increased PAP-significant PAH & systemic HT- ventricular dysfunction- dysrrhythmias CNS dysfunction: persistent hypercarbia

  40. OSA: clinical features

  41. OSA clinical features

  42. Evaluation: Gold standard: polysomnography Any age Diff 1ºsnoring & OSAS May predict success of treatment/ postop complications Desaturate with relatively short apneas: <10sec maybe significant Normal children: usually not > 1 apnea/hr

  43. Treatment : Surgery: Adenotonsillectomy Uvulopharyngoplasty Tongue reduction CPAP/ BIPAP SUPPLEMENTAL OXYGEN TRACHEOSTOMY

  44. Effect of treatment: Treating OSA by tonsillectomy &/or adenoidectomy is associated with increased gain in ht, wt & BMI in most children, including the obese &morbidly obese Neurobehavioral, cor-pulmonale improvement Zafer Soultan et al. Effect of Treating Obstructive Sleep Apnea by Tonsillectomy and/or Adenoidectomy on Obesity in Children. Pediatr Adolesc Med. 1999;153:33-37

  45. PREANESTHESIA EVALUATION Polysomnography ECG: PHT,RVH, cor- pulmonale ABG: metabolic acidosis, hypercarbia Antireflux medications Sedation: monitoring, titrated

  46. Anesthetic plan: Inhaled/ intravenous: titrated CPAP 10-15 cm Oral airway/ jaw thrust/ other Difficult airway management: FOB/ LMA Pain: opioid sparing adjuncts, non-opioid analgesics, nonpharmacological preferred Extubation: awake in OT/ ICU

  47. PERIOP COMPLICATIONS Apnea Pulmonary edema PHT crisis Pneumonia ICU care Prognosis: 13% recurrence

  48. Peritonsillar abscess Older children Severe sore throat, odynophagia, high fever, trismus Limited mouth opening-difficult airway Head down position, turned to side of abscess I &D: sedation/ topical/ LA/ GA Spontaneous breathing maintained Gentle laryngoscopy, suction Cuffed ETT

  49. Thank you www.anaesthesia.co.inanaesthesia.co.in@gmail.com

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