Guidelines for postponing tonsillectomy
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tonsillectomy postpone surgery acute infection fever guideline elective tonsillectomy
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tonsillectomy postponement infection
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https://pmc.ncbi.nlm.nih.gov/articles/PMC5829294
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elective paediatric surgery upper respiratory infection postpone anesthesia fever productive cough guidelines
For an elective tonsillectomy, postponement is generally appropriate when there is an active infection or increased anesthesia risk.
Common reasons to postpone
- Acute tonsillitis or pharyngitis: fever, severe sore throat, tonsillar exudate, swollen tender neck nodes, or currently taking treatment for an acute throat infection. Elective surgery is commonly deferred until the infection has fully settled. In the setting of a recent acute infection, a review recommends waiting at least 6 weeks if surgery is not being done urgently. Tonsil surgery review
- Current significant upper respiratory infection: fever, wheeze, a moist/productive cough, shortness of breath, lethargy, or copious nasal secretions. These increase risks such as laryngospasm, bronchospasm, and oxygen desaturation during anesthesia.
- Recent respiratory infection: timing depends on severity, age, asthma/OSA, and type of airway management. A common approach is at least 2 weeks after symptoms resolve for an uncomplicated URI, with consideration of 4 weeks for severe symptoms or higher-risk children. Some anesthetic guidance uses a 4 to 6 week interval because airway reactivity may persist. Pediatric anesthesia guidance
- Uncontrolled asthma or wheezing, or a recent asthma exacerbation.
- Dehydration, poor oral intake, vomiting, or a child who is systemically unwell.
- Bleeding risk not yet corrected: abnormal bleeding history, anticoagulant/antiplatelet management not resolved, thrombocytopenia, or significant anemia.
- Uncontrolled medical conditions or an anesthesia concern requiring optimization first.
Do not automatically postpone for
A mild, improving runny nose without fever, wheeze, chest symptoms, or reduced activity does not always require cancellation. The final decision should be made by the ENT surgeon and anesthetist after assessing symptom severity, age, OSA/asthma, and urgency of surgery. Children's Mercy review
Important exception
A peritonsillar abscess (quinsy) or airway-threatening infection may need urgent drainage or, less commonly, urgent tonsillectomy. This is not managed by simply waiting.
Contact the surgical team before the planned date if there is fever, new sore throat, antibiotics for an infection, cough with phlegm, wheeze, or poor intake. Seek urgent care for breathing difficulty, drooling, inability to swallow fluids, severe one-sided throat swelling, muffled voice, or neck swelling.
Allens test and modified allens test difference from standard source
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Allen test modified Allen test difference standard source radial artery cannulation
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Allen test modified test
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https://www.ncbi.nlm.nih.gov/books/NBK507816
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Difference between the Allen test and modified Allen test
Both assess collateral circulation of the hand, mainly whether the ulnar artery and palmar arches can maintain hand perfusion if the radial artery is occluded. This matters before radial arterial puncture, arterial-line insertion, radial artery harvest, or transradial catheterization.
| Feature | Original Allen test | Modified Allen test |
|---|---|---|
| Scope | Traditionally compares circulation in both hands/arteries | Tests one hand at a time and can specifically test ulnar or radial collateral flow |
| Clinical use | General assessment of palmar collateral circulation | More practical pre-procedure screen, especially before using the radial artery |
| Arteries compressed | Classically radial arteries are compressed bilaterally while comparing palmar color | Radial and ulnar arteries of the tested hand are compressed together |
| Artery released | Release/comparison is used to assess collateral filling | For radial cannulation: keep radial artery compressed and release ulnar artery |
| Interpretation | Compares return of color between hands | Prompt return of normal color indicates adequate ulnar collateral flow; delayed/absent return suggests inadequate collateral perfusion |
| Status | Historical original maneuver | Commonly used bedside version, though terms are sometimes used interchangeably |
Modified Allen test: usual steps
- Have the patient elevate the hand and repeatedly open and close it, then clench the fist to empty blood from the hand.
- Compress both radial and ulnar arteries at the wrist.
- Ask the patient to open the hand. The palm should look pale.
- Release the ulnar artery while maintaining radial compression.
- Observe for return of normal hand color, generally within about 5 to 6 seconds in one procedural-textbook method.
- Normal/negative test: rapid reperfusion, suggesting the ulnar artery can supply the hand if the radial artery becomes occluded.
- Abnormal/positive test: delayed or absent reperfusion, suggesting insufficient collateral supply.
Pfenninger and Fowler's Procedures for Primary Care, Third Edition, Assessment of Ulnar Collateral Circulation. The text advises that a positive or equivocal modified Allen test warrants caution and closer monitoring, rather than automatically prohibiting radial puncture/cannulation. It also states that Doppler assessment or pulse-oximetry waveform testing is more sensitive and specific than this subjective color-based test.
Important terminology point
In clinical teaching, people often call the modified Allen test simply the “Allen test.” If the context is an ABG, radial arterial line, or radial artery harvesting, the intended test is usually the modified version.
The NCBI clinical review similarly describes the modified test as the preferred single-hand method and notes that it can assess either ulnar or radial flow, depending on which vessel is kept compressed.
Criteria for diagnosing ms in view of rheumatic heart disease
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2020 ACC AHA rheumatic mitral stenosis echocardiographic diagnostic criteria valve area mean gradient
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rheumatic mitral stenosis echocardiography diagnosis
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https://www.jacc.org/doi/10.1016/j.jacc.2020.11.035
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Diagnosis of mitral stenosis (MS) in rheumatic heart disease
Echocardiography with Doppler is the diagnostic test of choice. Diagnosis rests on identifying the typical rheumatic valve morphology plus demonstrating obstruction to mitral inflow.
1. Typical rheumatic morphology on 2D echocardiography
Features that support rheumatic MS:
- Thickened mitral leaflets, especially at the tips
- Commissural fusion
- Diastolic doming of the anterior mitral leaflet, called the “hockey-stick” appearance
- Thickening, shortening, and fusion of chordae tendineae
- Reduced mitral leaflet mobility
- Often left atrial enlargement
Commissural fusion and leaflet doming distinguish rheumatic MS from degenerative/calcific MS, in which leaflet tips are usually relatively mobile and commissural fusion is absent. Textbook of Clinical Echocardiography, p. 348.
2. Hemodynamic confirmation and severity by Doppler echo
| Severity | Mitral valve area (MVA) | Mean transmitral gradient* |
|---|---|---|
| Mild | >1.5 cm² | <5 mmHg |
| Moderate | 1.0-1.5 cm² | 5-10 mmHg |
| Severe | ≤1.5 cm² | Usually >5-10 mmHg |
| Very severe | ≤1.0 cm² | Often >10 mmHg |
*The mean gradient is flow and heart-rate dependent. Tachycardia, anemia, pregnancy, exercise, atrial fibrillation, and significant mitral regurgitation can increase it. A low gradient does not exclude severe MS if cardiac output is low. Therefore, MVA is the main measure of severity, preferably by direct planimetry, with Doppler pressure half-time as a supportive method.
ACC/AHA staging defines severe rheumatic MS as MVA ≤1.5 cm². ACC/AHA valve guideline
3. Other supportive findings
These establish consequences of significant MS, rather than diagnose it alone:
- Left atrial enlargement
- Pulmonary hypertension, often PASP >50 mmHg in severe disease
- Atrial fibrillation
- Left atrial appendage thrombus or spontaneous echo contrast, assessed with TEE when needed
- Right ventricular enlargement/dysfunction and functional tricuspid regurgitation in advanced disease
4. Clinical findings supporting MS
- Exertional dyspnea, fatigue, orthopnea, hemoptysis, palpitations
- Low-pitched, mid-diastolic rumbling murmur at the apex, best heard with the bell in left lateral position
- Loud S1 and opening snap, although these may become soft or disappear in heavily calcified/immobile valves
- Loud P2 if pulmonary hypertension is present
Exam-style diagnostic statement
Rheumatic mitral stenosis is diagnosed by echocardiographic evidence of commissural fusion, diastolic doming and leaflet/subvalvular thickening, with reduced mitral valve area and increased transmitral diastolic flow velocity/gradient. Severe MS is defined by MVA ≤1.5 cm².
A recent systematic review relating to post-treatment outcomes in rheumatic MS is PMID 42031036. It does not alter these established diagnostic thresholds.
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