What are the preoperative preparations for a one-year-old child undergoing tonsillectomy?

Preoperative Preparation for Tonsillectomy in a One-Year-Old Child

For a one-year-old child undergoing tonsillectomy, preoperative preparation must include mandatory polysomnography if the indication is obstructive sleep-disordered breathing, documentation of specific surgical indications, assessment for high-risk comorbidities, and planning for mandatory overnight inpatient monitoring given the child's age. 1, 2

Critical Age-Specific Considerations

Children under 3 years of age require mandatory overnight inpatient monitoring after tonsillectomy, regardless of OSA severity, due to a significantly higher respiratory complication rate (9.8% versus 4.9% in older children). 2 This is a non-negotiable requirement for your one-year-old patient and must be arranged preoperatively. 1

Preoperative Assessment Requirements

Documentation of Surgical Indication

You must clearly document one of two specific indications 1, 2:

• Obstructive sleep-disordered breathing: Document snoring, witnessed apneas, mouth breathing, daytime somnolence, or growth retardation 1
• Recurrent throat infections: Though rare at age one, this would require documentation of infection frequency (note: watchful waiting is recommended if <7 episodes in past year, <5 episodes per year over 2 years, or <3 episodes per year over 3 years) 1

Mandatory Polysomnography

Polysomnography is required before surgery for any child under 2 years of age with obstructive sleep-disordered breathing. 1, 2 This is a strong recommendation from the American Academy of Otolaryngology-Head and Neck Surgery specifically for your patient's age group. The results will determine:

• Severity of OSA (apnea-hypopnea index)
• Oxygen saturation nadir
• Need for enhanced postoperative monitoring 2

Assessment for High-Risk Comorbidities

Screen and document the presence or absence of 1, 2:

• Obesity
• Down syndrome
• Craniofacial abnormalities
• Neuromuscular disorders
• Sickle cell disease
• Mucopolysaccharidoses

These conditions mandate polysomnography and may require additional perioperative precautions. 1

Bleeding Risk Assessment

Obtain a standardized bleeding history, which is superior to routine coagulation tests. 3 Document:

• Personal history of abnormal bleeding
• Family history of bleeding disorders
• Prior surgical procedures and any bleeding complications
• Current medications

Routine coagulation screening is not recommended unless the history suggests a bleeding disorder. 3

Intraoperative Planning

Mandatory Interventions

Document the plan for these evidence-based interventions 1, 2:

• Single intraoperative dose of IV dexamethasone (strong recommendation): Reduces postoperative nausea/vomiting, decreases time to first oral intake, and lowers pain scores 1, 2
• No perioperative antibiotics (strong recommendation against): Provides no benefit and contributes to antibiotic resistance 1, 2

Postoperative Planning

Admission and Monitoring

Arrange mandatory overnight inpatient admission with continuous pulse oximetry and availability of respiratory support. 2 This is required for all children under 3 years of age. 1, 2

If polysomnography shows severe OSA (AHI ≥10 obstructive events/hour or oxygen saturation nadir <80%), enhanced monitoring protocols are needed. 2

Pain Management Plan

Plan for ibuprofen, acetaminophen, or both for postoperative pain control (strong recommendation). 1, 2

Never prescribe codeine or any codeine-containing medication (strong recommendation against for children under 12 years). 2 This is a critical safety issue related to variable metabolism and risk of respiratory depression. 1

Follow-up Planning

Schedule follow-up to assess for 2:

• Primary bleeding (occurs within 24 hours; rate approximately 6.27%) 4
• Secondary bleeding (occurs days later; rate approximately 0.48%) 4
• Resolution of presenting symptoms
• Feeding adequacy and hydration status

Common Pitfalls to Avoid

• Failing to obtain polysomnography in a child under 2 years: This is mandatory for obstructive sleep-disordered breathing indications 1, 2
• Planning outpatient surgery: Children under 3 years require overnight admission 2
• Prescribing codeine: This is contraindicated in children under 12 years 2
• Ordering routine coagulation tests: A standardized bleeding history is superior 3
• Planning to use perioperative antibiotics: These provide no benefit 1, 2
• Forgetting to order intraoperative dexamethasone: This is a strong recommendation with clear benefits 1, 2