In this section
Tonsillectomy +/- adenoidectomy is a surgical procedure commonly performed at The Royal Children’s Hospital.
Surgery is most commonly performed for children who have Obstructive Sleep Apnoea, Sleep Disordered Breathing and recurrent tonsillitis.
To provide nursing staff with a guideline for the postoperative management of children who undergo tonsillectomy +/- adenoidectomy so that care can be standardised across all inpatient wards, Day of Surgery and Wallaby.
Please note this is a plan specific for patients who have undergone surgery at RCH, it relates to both inpatients admitted overnight at RCH and/or Wallaby. Education should be provided about the analgesia regimen to parents/carers on discharge.
First line of pain management post operatively:
Type of Medication
Frequency/ Special Instructions
Given strictly every 6 hours including overnight for a minimum of 7 days. Continue to administer as required up to 10-14 days.
Given 3 times a day, 8 hrs apart for a minimum of 7 days.
NOT to be given with other NSAIDS (e.g. Celecoxib).
The recommended dose at RCH for patient’s post T & A is 4mg/kg up to a maximum of 200mg BD, given regularly for 7 days. To be commenced day 1 post operatively.
NOT to be given with other NSAID (e.g. Ibuprofen)
Ibuprofen is safe to use in patients post Tonsillectomy +/- Adenoidectomy, however this should not be administered with other NSAIDS (e.g. Celecoxib).
Second line of pain management post operatively, or “break though pain”:
Frequency/ Special Instructions
Given only for breakthrough pain relief.
RCH does not recommend the prescription of tramadol drops, instead tramadol capsules are ordered, and nursing staff are to disperse in water and give the recommended dosage.
Example of a sleep diary progress note:
2200: settled to sleep, commenced overnight oximetry (trend data cleared). Nil noisy breathing.
0130: brief desaturation to 89% on RA, lasting less than 2 seconds. Self-resolving, patient sleeping on their side, patient then coughed and stirred in his sleep. Sp02 back up to 95% on RA.
<83% on RA- poor trace, moving around in bed. Artifact. Probe checked. Once patient settled, good trace sp02 at 97% on RA.
0400: desaturation 86% and dropping to 81% over 5 seconds, not self-resolving. Loud obstructive snore, tracheal tug noted. Nursing staff repositioned patient onto their side as patient laying on their back. Sp02 returned to 96% after repositioning.
0525: probe disconnect as patient went to bathroom
0530: reconnected probe
0700: oximetry turned off & report downloaded for review.
Maintain IV access until the day of discharge, for more information please refer to Peripheral Intravenous IV Device Management Guideline.
For further information regarding management of oxygen delivery, please review
Clinical Guidelines (Nursing) : Oxygen delivery (rch.org.au)
*If starting Humidified High Flow Nasal Therapy Air
If no improvement with Humidified High Flow Nasal Air - notify PICU Outreach
For further information regarding management of HFNP therapy, please review
High Flow Nasal Prong (HFNP) Therapy Guideline.
The use of High Flow Nasal Prong Air for the management of children who have oxygen desaturations after T&A has been approved by the Royal Children’s Hospital New Technology and Clinical Practice Committee. In the protocol it has also been approved that insertion of a nasogastric tube is not needed due the potential to cause trauma and bleeding post tonsillectomy & adenoidectomy.
A patient whose oxygen saturations are 90-93% in room air falls within the orange zone on the ViCTOR chart. In line with the
MET Modification Policy, These patients require a clinical review. A nursing review with the bedside nurse and ANUM is required, a documentation of the rationale and plan of care should be carried out and discussed with the family.
Remember that you can request a Rapid Review or a MET call at any time.
If airway, breathing or circulation is compromised call a MET or Resus Team
Please note the following refers to patients admitted to RCH only
Day case tonsillectomy +/- adenoidectomy with transfer to Wallaby (Hospital-in-the-home) for ongoing support may be appropriate for some low-risk patients with symptoms of OSA or recurrent tonsillitis.
Current patient eligibility criteria:
Children seen in the preoperative ENT clinic with symptoms of OSA or recurrent tonsillitis are considered for Wallaby transfer post day case T’s +/- A’s, according to the following eligibility criteria:
Patient completes up to 4 hours postoperative observation in recovery/day surgery and may then discharge if:
Please remember to
read the disclaimer.
The development of this nursing guideline was coordinated by Bec Marshall and Claire De Simone, CNC, Department of Otolaryngology, and approved by the Nursing Clinical Effectiveness Committee. Revised December 2022.