Anaesthetic considerations: 5-year-old, 15 kg, for adenotonsillectomy

1. Preoperative assessment

• Confirm indication and screen for OSA / sleep-disordered breathing
  • Snoring, witnessed apnoea, restless sleep, daytime somnolence or behavioural issues.
  • Review sleep study if available: severe OSA includes AHI ≥10/hour and/or oxygen nadir <80%.
  • Ask about obesity, craniofacial abnormalities, Down syndrome, neuromuscular disease, pulmonary hypertension and congenital heart disease.
  • Children with OSA have increased postoperative respiratory risk and greater opioid sensitivity.
• Airway and respiratory assessment
  • Tonsil size, mouth opening, dentition, nasal obstruction, stridor, wheeze, asthma control.
  • Specifically ask about recent URTI: fever, productive/moist cough, purulent nasal discharge, wheeze, reduced activity. Elective airway surgery is often deferred for a significant active respiratory infection because airway reactivity and laryngospasm/bronchospasm risk are higher.
  • Consider preoperative salbutamol if reactive airway disease or recent respiratory symptoms, according to local protocol.
• Bleeding risk
  • Personal or family history of easy bruising, epistaxis, prolonged bleeding after dental extraction/surgery, use of anticoagulant or antiplatelet drugs.
  • Routine coagulation testing is not needed in a child without a bleeding history or relevant clinical findings.
• Fasting, consent and preparation
  • Standard fasting regimen: clear fluids up to 2 h, breast milk up to 4 h, light meal/formula up to 6 h, subject to institutional policy.
  • Explain possibility of postoperative admission, reoperation for haemorrhage, and rare airway complications.
  • Ensure suitable paediatric equipment, suction, difficult-airway plan, blood availability based on risk and local practice.

2. Intraoperative plan

• Standard ASA monitoring: ECG, SpO₂, NIBP, capnography, temperature.
• Secure IV access. A second IV may be sensible for difficult access, high bleeding risk, severe OSA, or comorbidity.

• Either inhalational induction with sevoflurane or IV induction is appropriate.
• Maintain airway patency carefully, especially in severe OSA or marked adenotonsillar hypertrophy.
• Avoid heavy sedative premedication in clinically significant OSA unless closely monitored.

• Usually use a cuffed oral RAE endotracheal tube, well secured away from the surgical field.
• Confirm tube placement with continuous capnography.
• A throat pack may be used by the surgeon, but it must be clearly documented and removed before extubation. Use a formal throat-pack check.
• Shared-airway communication with ENT surgeon is essential, particularly during placement/removal of gag, repositioning of tube, and management of bleeding.

• Controlled ventilation with oxygen/air and volatile anaesthetic or TIVA, as appropriate.
• Humidification and gentle airway handling help limit laryngospasm/bronchospasm.
• Avoid nitrous oxide if significant concern for postoperative nausea/vomiting or if local practice prefers avoidance.

• Give paracetamol: 15 mg/kg = 225 mg IV or oral, accounting for all preoperative doses.
• Use a low-dose opioid only if required, titrated to response. In suspected or confirmed OSA, minimize opioids and observe closely.
• NSAID use, such as ibuprofen, is guideline-supported for post-tonsillectomy analgesia when not contraindicated. Typical ibuprofen dose: 10 mg/kg = 150 mg orally.
• Do not use codeine. Avoid tramadol as well in this setting, particularly after adenotonsillectomy and in children with OSA.

• Adenotonsillectomy has a high PONV risk.
• Give a single intraoperative IV dose of dexamethasone, commonly 0.15 mg/kg = 2.25 mg in this child, with dosing/maxima per local policy.
• Add ondansetron, commonly 0.1 mg/kg = 1.5 mg IV, subject to local protocols and contraindications.
• The AAO-HNS guideline recommends single-dose intraoperative IV dexamethasone, and recommends acetaminophen and/or ibuprofen for postoperative pain control. It also advises against routine perioperative antibiotics and against codeine after paediatric tonsillectomy. AAO-HNS guideline summary

• Anticipate swallowed blood and postoperative nausea.
• Estimate blood loss, ensure IV access remains patent, and replace volume if necessary.
• Gastric suction via an orogastric tube can be considered at the end, particularly if there has been appreciable swallowed blood, while avoiding traumatic insertion.

3. Emergence and extubation

• Ensure meticulous oral suctioning under direct vision. Avoid blind deep suctioning that can traumatize the operative site.
• Confirm removal of throat pack, surgical instruments and blood clots.
• Extubate fully awake, with intact airway reflexes and good spontaneous ventilation, generally in lateral or head-up positioning.
• Be ready for laryngospasm, airway obstruction, bronchospasm, desaturation or bleeding.
• Have suction immediately available during transport and recovery.

4. Postoperative care and disposition

• Recovery should include continuous pulse oximetry until the child is awake, maintaining baseline oxygenation, drinking appropriately, and has satisfactory pain/nausea control.
• Watch for airway obstruction, apnoea, hypoxaemia, laryngospasm, excessive sedation, vomiting/aspiration and primary haemorrhage.
• Admit overnight if:
  • age <3 years
  • severe OSA, such as AHI ≥10/hour or oxygen nadir <80%
  • significant obesity, syndromic/craniofacial disease, neuromuscular disease, pulmonary hypertension or major comorbidity
  • persistent oxygen need, recurrent desaturation/apnoea, poor oral intake, uncontrolled pain or bleeding.

Key viva summary

In a 5-year-old for adenotonsillectomy, I would assess OSA severity, URTI/asthma and bleeding history; use standard paediatric monitoring and a secured cuffed oral RAE tube for the shared airway; provide multimodal opioid-sparing analgesia with paracetamol, NSAID if appropriate, dexamethasone and antiemetic prophylaxis; extubate fully awake after checking removal of the throat pack; and provide close recovery monitoring, with overnight admission for severe OSA or other high-risk features.