Tonsillectomy and adenoidectomy post operative nursing management

  • Introduction

    Aim

    Definition of Terms

    Assessment

    Management 

    Special Considerations

    Companion Documents

    Links

    Evidence Table

    Introduction

    Tonsillectomy is a surgical procedure commonly performed at The Royal Children’s Hospital, often with an adenoidectomy.
    Surgery is performed most commonly for children who have Obstructive Sleep Apnoea, Sleep Disordered Breathing and recurrent tonsillitis.

    Aim

    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 units. 

    Definition of Terms 

    • Tonsillectomy: The surgical removal of the tonsils
    • Adenoidectomy: The surgical removal of the adenoids
    • Obstructive Sleep Apnoea: Complete or partial obstruction of the upper airway which presents as snoring with pauses in breathing while asleep. For most young children this is often from large tonsils and adenoids but can also be due to the relaxation of the tongue and airway muscles. 
    • T & A: Tonsillectomy and Adenoidectomy

    Assessment 

    • Routine Post Anaesthetic Observations are required for all patients post tonsillectomy. Please refer to Routine Post Anaesthetic Observation Guideline.
    • All children should have continuous oximetry when they are asleep. 
    • All children who stay overnight should be placed on a Nellcor™ downloadable oximeter overnight, an order should be placed in EMR for overnight oximetry. This report is downloaded and printed in the morning if the child has had desaturations or if the nurse was concerned about the patient’s breathing.
    • Regular pain assessments, please refer to the Pain Assessment and Measurement Guideline.
    • All patients should continue on 4 hourly observations until discharge, for more information please refer to Nursing Assessment Guideline.

    Management 

    Early management 

    • The greatest risk of primary bleeding is within the first 6 hours; patients going home via day surgery should be observed for 6 hours prior to discharge.
    • Diet should be introduced as soon as possible, there are no restrictions on what children can eat however they may prefer a soft and cool diet.
    • Analgesia should be given strictly, including waking children overnight.

    Analgesia Regimen – RCH Specific

    Medication Name Type of Medication Frequency/ Special Instructions
    Parecoxib An intravenous selective COX-2 inhibitor STAT dose given intraoperatively.
    Celecoxib An oral COX-2 inhibitor 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.
    Paracetamol Simple Analgesic Given strictly every 6 hours including overnight for the first few post-operative nights, and regularly for 7 days.
    Tramadol Synthetic opioid like analgesic for moderate to severe pain Given only for breakthrough pain relief and is the preferred opioid.
    Oxycodone Narcotic analgesic for severe pain

    Caution should be taken with children who have OSA.

    Please note that Tramadol is the preferred opioid in this patient group.

    • 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.
    • At RCH our surgeons recommend that in order to reduce the risks from post-tonsillectomy bleeding, ibuprofen should not be administered. 

    Ongoing management

    • Children with OSA who are yet to pass a night on overnight oximetry should be placed on continuous monitoring while they sleep (A child who has passed overnight oximetry will have been monitored overnight and not had any oxygen desaturations).
    • Overnight downloadable oximetry should be repeated if the patient failed to pass the first night.
    • Maintain IV access until the day of discharge.
    • All patients should be given the Tonsils and adenoids removed – discharge care Kids health info factsheet along with the Tramadol Pharmacy factsheet and the Celecoxib Kids health info factsheet. In depth discussion regarding analgesia, diet and oral intake, activity at home and risk of secondary bleeding should take place with the family prior to discharge from RCH
    • Discharge Criteria / Follow Up
    • Most children can be placed on a Criteria Led Discharge for the next morning post-operatively
    • Patient must be tolerating diet and fluids
    • Pain controlled
    • Tonsil bed inspection by competent nurses or ENT staff
    • Downloadable oximetry reviewed by ENT Registrar if applicable
    • Afebrile and other observations within age appropriate limits 
    • Family state that they understand the care at home
    • Follow up is usually with the GP in 2 weeks, unless stated otherwise. 
    • Ensure discharge scripts are filled at the RCH pharmacy. Celecoxib suspension is not usually available at external pharmacies

    Special Considerations

    Managing Oxygen Desaturations

    • Children with chronic obstructive sleep apnoea may have hypoxia and hypercarbia. The administration of oxygen in this patient group may cause apnoea or mask the obstruction and hypercarbia.
    • Oxygen should not be applied to this patient group without consultation with ENT staff or the Medical Lead after hours unless in a life threatening situation.
    • If a patient’s oxygen saturations begin to drop, rouse and reposition them. If this happens more than 3 times in one hour the patient requires a medical review.
    • If oxygen saturations do not spontaneously resolve with repositioning a rapid review or MET should be called.
    • Report any difficulty breathing to ENT or the after-hours medical team.

    Managing Post-Operative Bleeding

    • Post tonsillectomy bleeding is uncommon (5% of patients), but is a potentially life threatening event
    • The main difficulties arise from aspiration of blood and hypovolaemic shock
    • Primary (not common) – within 24 hours of surgery
    • Will likely need to return to theatre
    • Secondary – most commonly at day 5 to 10 post surgery 
    • Usually self-limiting and do not require return to theatre
    • Usually require observation in hospital as there may be a second bleed
    • Report any bleeding to the ENT Registrar on call and the Nurse in Charge.
    • Keep the patient nil by mouth. Consider antiemetic if patient nauseated.
    • Record estimated amount of blood loss (note that bleeding may be haemoptysis or haematemesis as children often swallow blood).
    • Allow patient to sit upright, leaning forward to assist in keeping blood out of airway.
    • Monitor for signs and symptoms of hypovolemic shock. Consider the need for continuous cardiac monitoring.
    • If no active bleeding, keep patient nil by mouth for 6 hours or until review in the morning.

    If airway, breathing or circulation is compromised call a MET or Resus Team

    Companion Documents

    Links

    Evidence Table


    Please remember to read the disclaimer.



    The development of this nursing guideline was coordinated by Claire De Simone, ANUM, Possum Ward, and approved by the Nursing Clinical Effectiveness Committee. First published May 2019.