What are the anesthesia considerations for adenotonsilectomy?

Anesthesia Considerations for Adenotonsillectomy

Adenotonsillectomy patients require careful preoperative assessment for obstructive sleep apnea (OSA) and risk stratification, with mandatory communication of polysomnography results to the anesthesiologist prior to induction to reduce perioperative morbidity and mortality. 1

Preoperative Assessment

OSA Screening and Risk Stratification

• Polysomnography (PSG) is essential before surgery for high-risk patients 2:

  • Children with obesity
  • Down syndrome
  • Craniofacial abnormalities
  • Neuromuscular disorders
  • Sickle cell disease
  • Mucopolysaccharidoses

• Children with OSA are at 8-fold increased risk for difficult airway 1

• Assess for cardiac complications of OSA (e.g., right ventricular hypertrophy) 1

• Screen for recent respiratory infections which increase complication risk 1

Risk Factors for Perioperative Complications

• Age younger than 3 years 1
• Severe OSA (AHI >10 or oxygen saturation nadir <80%) 2
• Failure to thrive or obesity 1
• Prematurity history 1
• Craniofacial anomalies 1
• Neuromuscular disorders 1

Intraoperative Management

Airway Management

• Prepare for potentially difficult airway in OSA patients 1
• Have appropriate airway equipment and assistance available in the operating room 1
• Both laryngeal mask airway and endotracheal tube are acceptable options based on team experience 3

Anesthetic Considerations

• Avoid premedication/sedatives in OSA patients due to risk of oversedation and hypoventilation 1
• Carefully titrate anesthetic gases due to increased susceptibility to airway collapse 1
• Use caution with nitrous oxide in patients with OSA who may be at risk for pulmonary hypertension 1
• Administer a single, intraoperative dose of intravenous dexamethasone (strong recommendation) 1
• Avoid routine perioperative antibiotics (strong recommendation against) 1

Analgesic Strategy

• Consider opioid-sparing or opioid-free anesthesia techniques 4, 5:
  • Dexmedetomidine and ketorolac combination provides effective analgesia without increasing recovery times 4
  • Multimodal approach with acetaminophen and NSAIDs as baseline medications 3
  • Local anesthetic infiltration may be beneficial 3
• Reduce or withhold intraoperative opioids in OSA patients due to increased analgesic sensitivity 1
• NEVER administer codeine to children under 12 years after tonsillectomy 2

Postoperative Management

Monitoring Requirements

• High-risk patients should be hospitalized overnight and monitored continuously with pulse oximetry 1
• PICU monitoring recommended for severe OSA (AHI >10 or oxygen saturation nadir <80%) 2
• All children under 3 years require overnight observation 2

Pain Management

• Use ibuprofen and acetaminophen for postoperative pain control 2
• Avoid opioids when possible, especially in OSA patients 1, 5
• Monitor for respiratory depression if opioids are required 1

Complications to Monitor

• Respiratory complications (worsening OSA, pulmonary edema) 1
• Postoperative bleeding (can occur up to 2 weeks after surgery) 6
• Pain, otalgia, and dehydration 6, 7
• Nausea and vomiting (reduced with dexamethasone, ondansetron, and propofol) 3

Special Considerations

• Patients with OSA may require modified anesthetic approach and postoperative care 1
• Communication between surgeon and anesthesiologist is critical regarding OSA severity 1
• Post-operative polysomnography is recommended for children with severe preoperative OSA or persistent symptoms 2
• Recognize that death attributable to severe respiratory complications has been reported in patients with severe OSA 1

By following these evidence-based guidelines, anesthesiologists can minimize perioperative risks and optimize outcomes for patients undergoing adenotonsillectomy.