What are the guidelines for post-operative tonsillectomy ward management?

Post-Operative Tonsillectomy Ward Management

Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (OSA; apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). 1

Monitoring Requirements

High-Risk Patients Requiring Inpatient Monitoring

• Children younger than 3 years of age require overnight inpatient monitoring regardless of OSA severity 1
• Children with severe OSA (defined as AHI ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both) require overnight monitoring 1
• Patients with comorbidities including Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses require more intensive monitoring 1
• Children with very severe OSA (AHI >30) may require PICU admission rather than standard ward monitoring 1

Monitoring Parameters

• Continuous pulse oximetry monitoring is recommended for all hospitalized children post-tonsillectomy 1
• Regular assessment of respiratory status, particularly in the first 24 hours when respiratory complications are most common 1
• Monitor for signs of upper airway obstruction, which may persist or worsen in the immediate postoperative period despite removal of tonsils 1

Pain Management Protocol

First-Line Medications

• Implement multimodal analgesia with scheduled (not as-needed) administration of medications 1, 2
• Administer ibuprofen and acetaminophen as baseline therapy for pain control 1, 2
• A single intraoperative dose of intravenous dexamethasone should be administered for its analgesic and anti-emetic effects 1, 2

Opioid Considerations

• If opioids are necessary for severe pain, they should be used at reduced doses with careful titration and continuous pulse oximetry monitoring 1
• Codeine and medications containing codeine must not be administered or prescribed after tonsillectomy in children younger than 12 years 1
• Reserve opioids only as rescue medication when other measures are insufficient 2

Adjunctive Pain Management

• Honey can be used postoperatively as an analgesic adjunct with no reported side effects 2
• Ice popsicles/lollies can provide temporary pain relief in the immediate postoperative period 2
• Encourage adequate hydration to prevent dehydration, which can worsen pain 2, 3

Complications Management

Bleeding Assessment

• Monitor for signs of primary bleeding (within 24 hours of surgery) and secondary bleeding (occurring later than 24 hours after surgery) 1
• Primary bleeding typically occurs within 75 minutes of arrival in the recovery room 4
• Document the presence or absence of bleeding in the medical record 1
• Determine the rate of primary and secondary post-tonsillectomy bleeding at least annually 1

Respiratory Complications

• Postoperative respiratory complications occur in 5.8% to 26.8% of children with OSA undergoing tonsillectomy, compared to 1.3% to 2.4% in the general pediatric population 1
• Most interventions required during the postoperative period include administration of oxygen or repositioning 1
• Be prepared for more significant interventions including CPAP or reintubation in severe cases 1

Other Complications

• Monitor for dehydration due to decreased oral intake and dysphagia 1, 5
• Assess for postoperative nausea and vomiting, which can be reduced with dexamethasone 1, 6
• Fever can be managed with the same analgesic regimen (acetaminophen and NSAIDs) that addresses pain 2

Discharge Planning

Discharge Criteria

• Resolution of immediate postoperative respiratory concerns 1
• Adequate pain control with oral medications 2
• Sufficient oral intake to maintain hydration 2
• No signs of active bleeding 7
• Patient/caregiver education on pain management and recognition of complications completed 2

Follow-up Requirements

• Follow up with patients and/or caregivers after tonsillectomy 1
• Document the presence or absence of bleeding within 24 hours of surgery and any secondary bleeding 1
• Counsel patients and caregivers that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management 1

Common Pitfalls and Caveats

• Previous concerns about NSAIDs increasing bleeding risk have not been substantiated in recent studies and meta-analyses 1, 2
• Pain after tonsillectomy can last 11-12 days, requiring adequate analgesia planning beyond the immediate postoperative period 8
• Inadequate pain control can lead to poor oral intake, dehydration, and potential readmission 5
• Patients with OSA have nearly 5 times more respiratory complications after surgery compared with children without OSA 1