What are the preoperative preparation steps for a patient undergoing tonsillectomy?

Preoperative Preparation for Tonsillectomy

Preoperative preparation for tonsillectomy should focus on risk stratification, patient/caregiver education about pain management, and selective use of polysomnography—while avoiding routine coagulation testing and perioperative antibiotics.

Risk Assessment and Documentation

Indication Documentation

• Document the specific indication for tonsillectomy (recurrent throat infection vs. obstructive sleep-disordered breathing) with frequency criteria clearly noted 1
• For recurrent throat infections, note if criteria are met: ≥7 episodes in past year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years 1
• Document any comorbid conditions that may improve post-tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems 1

Polysomnography Considerations

• Order preoperative polysomnography for high-risk children: those <2 years old, or with obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses 1
• Polysomnography is not routinely necessary for all children undergoing tonsillectomy 2
• Document AHI (apnea-hypopnea index) and oxygen saturation nadir when polysomnography is performed, as these determine postoperative monitoring needs 1

Coagulation Testing

• Do not perform routine preoperative coagulation testing if clinical history is negative for bleeding disorders 2
• A thorough bleeding history is sufficient; routine coagulation profiles are unnecessary and have limited predictive value 3, 2
• Reserve coagulation testing only for patients with positive bleeding history or known coagulation disorders 2

Patient and Caregiver Education

Pain Management Education

• Educate caregivers preoperatively about pain management strategies, emphasizing that pain may last up to 2 weeks 4
• Explain that antibiotics do not reduce postoperative pain and should not be given routinely 4
• Emphasize that maintaining adequate hydration is associated with less pain 4
• Instruct caregivers to give pain medication on a regular schedule rather than waiting for the child to complain of pain 4
• Provide written educational materials or brochures documenting this education 4

Child-Centered Preparation

• Address children's specific concerns about operation procedures, experiencing "soreness" and discomfort postoperatively, and parental presence 5
• Use child-centered information leaflets with a question-and-answer format 5
• Involve mothers as primary information providers, as children view them as best situated to provide information 5

Warning Signs Education

• Educate about signs requiring immediate medical attention: fresh bleeding, respiratory distress, severe pain uncontrolled by medications, and signs of dehydration 6

Medication Planning

Intraoperative Medications to Plan

• Plan for mandatory single intraoperative dose of IV dexamethasone (0.15-1.0 mg/kg, maximum 8-25 mg) 4, 1
• This reduces postoperative nausea/vomiting, decreases time to first oral intake, and lowers pain scores 1

Postoperative Pain Medications to Prescribe

• Prescribe ibuprofen and/or acetaminophen for postoperative pain control 1
• Do NOT prescribe codeine or any codeine-containing medications for children under 12 years 1
• Avoid routine opioid prescriptions; reserve as rescue medication only 6

Medications to Avoid

• Do NOT order perioperative antibiotics (strong recommendation against) 4, 1
• Antibiotics provide no benefit for pain, bleeding, or recovery and contribute to antibiotic resistance 4
• The only exceptions are patients requiring endocarditis prophylaxis or those with implants 4

Postoperative Monitoring Planning

Determine Need for Overnight Observation

• Arrange overnight inpatient monitoring for children <3 years old (regardless of OSA severity) 4, 1
• Arrange overnight inpatient monitoring for children with severe OSA: AHI ≥10 events/hour, oxygen saturation nadir <80%, or both 4, 1
• Children <3 years have higher respiratory complication rates (9.8% vs. 4.9% in older children) 1
• Plan for continuous pulse oximetry and availability of respiratory support for high-risk patients 1, 6

Common Pitfalls to Avoid

• Failing to educate about pain management preoperatively—this is a critical component that reduces postoperative morbidity 4
• Ordering routine coagulation tests—these are unnecessary and not cost-effective with negative bleeding history 2
• Prescribing perioperative antibiotics—this provides no benefit and increases antibiotic resistance 4
• Prescribing codeine for children under 12—this is contraindicated due to safety concerns 1
• Inadequate risk stratification—failing to identify children who need polysomnography or overnight monitoring increases respiratory complication risk 1, 2
• Forgetting to plan for intraoperative dexamethasone—this single intervention significantly reduces multiple postoperative morbidities 4, 1