Can a 3-year-old patient be discharged on day 6 post tonsillectomy (tonsil removal) and adenoidectomy (adenoid removal) with elevated white blood cell count (leukocytosis) and C-reactive protein (CRP) level, despite being clinically well?

From the Guidelines

The 3-year-old patient can likely be discharged if they are clinically well despite the elevated white blood cell count (15) and C-reactive protein (37) on day 6 post-tonsillectomy and adenoidectomy, as these mildly elevated inflammatory markers are not uncommon following surgical procedures, particularly in the first week post-operation 1. Since the child is described as "otherwise clinically well" with no symptoms of infection such as fever, increased pain, purulent discharge, or dehydration, discharge is reasonable.

Key Considerations for Discharge

• Parents should be instructed to monitor for warning signs including:
  • Fever over 101°F (38.3°C)
  • Increased pain
  • Refusal to drink
  • Bleeding from the surgical site
  • Worsening lethargy
• Ensure the child maintains adequate hydration with cool, non-acidic fluids
• Continue any prescribed pain medications such as acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours) as needed, as recommended by recent guidelines 1
• A follow-up appointment should be scheduled within 1-2 weeks
• Parents should be provided with clear instructions on when to seek immediate medical attention

Postoperative Care

The importance of managing posttonsillectomy pain as part of the perioperative education process should be emphasized, and reminders about the need to anticipate, reassess, and adequately treat pain after surgery should be given 1. Nonpharmacologic interventions such as relaxation, distraction, and cold or heat application can supplement pharmacologic agents for posttonsillectomy pain management 1.

Evidence-Based Recommendations

Recent clinical practice guidelines recommend against the administration of perioperative antibiotics to children undergoing tonsillectomy 1 and support the use of ibuprofen, acetaminophen, or both for pain control after tonsillectomy 1. The guidelines also emphasize the importance of follow-up with patients and/or caregivers after tonsillectomy to document the presence or absence of bleeding within 24 hours of surgery and bleeding occurring later than 24 hours after surgery 1.

Given the child's age and the fact that they are clinically well, discharge with proper instructions and follow-up is the most appropriate course of action, prioritizing the child's morbidity, mortality, and quality of life outcomes 1.

From the Research

Patient Discharge Considerations

• The patient is a 3-year-old, 6 days post-MLTB+ dissection tonsillectomy + suction monopolar adenoidectomy, with a white blood cell count of 15 and CRP of 37, and is otherwise clinically well.
• The provided studies do not directly address the discharge criteria for a patient with these specific characteristics.
• However, some studies provide insight into the relationship between white blood cell count, CRP levels, and infection or inflammation:
  • A study from 2008 2 found that febrile patients with normal white blood cell counts and high CRP levels often had bacterial infections, but this study was conducted in adults and may not be directly applicable to a 3-year-old patient.
  • A 2022 study 3 discussed the dynamics of white blood cell and platelet populations in acute inflammatory recovery, but did not provide specific guidance on discharge criteria.
  • Other studies 4, 5, 6 focused on the role of CRP in various conditions, such as liver injury, spinal cord injury, and diabetes, but did not address discharge criteria for post-surgical patients.

Laboratory Results

• The patient's white blood cell count is elevated at 15, which may indicate an inflammatory response or infection.
• The CRP level is 37, which is also elevated and may indicate inflammation or infection.
• However, without more specific guidance from the provided studies, it is difficult to determine the significance of these laboratory results in the context of discharge criteria.

Clinical Considerations

• The patient is otherwise clinically well, which suggests that they may be recovering from the surgery without significant complications.
• However, the elevated white blood cell count and CRP level may indicate an ongoing inflammatory response or infection that requires further monitoring or treatment.
• The decision to discharge the patient should be based on a comprehensive evaluation of their clinical condition, laboratory results, and other relevant factors, rather than relying solely on the provided studies.