Tonsillectomy and adenoidectomy (T&A) are among the most commonly performed pediatric surgeries. Transitioning these procedures from hospitals to ambulatory surgery centers (ASCs) offers benefits in cost and convenience. However, the ASC setting requires heightened attention to airway management, bleeding risks, and post-anesthesia recovery. A comprehensive safety protocol ensures that pediatric T&A cases are conducted safely and efficiently in the outpatient environment.
Effective preoperative screening is essential. The Pediatric Sleep Questionnaire (PSQ) is preferred for evaluating obstructive sleep apnea (OSA) risk. A score of eight or more positive responses indicates moderate to severe OSA. Patients with an apnea-hypopnea index (AHI) greater than 10 should undergo surgery in a hospital setting.
Certain comorbidities also warrant hospital-based care. These include cyanotic congenital heart disease, craniofacial abnormalities such as Pierre Robin sequence, extreme obesity with concurrent asthma requiring steroids, and any known bleeding disorders, including von Willebrand disease or factor deficiencies.
Midazolam at a dose of 0.5 mg per kg orally (up to a maximum of 15 mg) is commonly used for anxiolysis before induction. Mask induction using sevoflurane with 70 percent nitrous oxide supports a smooth intravenous start while maintaining airway tone. Intravenous agents such as ketamine (0.5 mg per kg) and propofol (2 mg per kg) provide hemodynamic stability and reduce the risk of emergence delirium.
A cuffed endotracheal tube, sized according to the formula (age divided by 4 plus 3.5), allows for better control of anesthetic gases and minimizes fire risk. Dexamethasone, dosed at 0.5 mg per kg with a maximum of 10 mg, is recommended to reduce postoperative nausea, swelling, and throat discomfort.
Continuous monitoring of oxygen saturation and end-tidal carbon dioxide is required, with inspired oxygen concentrations kept at or below 30 percent to minimize surgical fire risk. Because visual estimation of blood loss is unreliable in T&A procedures, suction canister output minus irrigation volume should be used to track actual blood loss.
Analgesia should begin with intravenous acetaminophen at 15 mg per kg and fentanyl at 1 microgram per kg. Morphine may be used as a rescue medication if needed.
Thorough suctioning of the oropharynx before extubation reduces the risk of aspiration. Deep extubation is typically preferred to avoid coughing and agitation, provided the patient demonstrates spontaneous ventilation. Patients should be positioned laterally or prone during emergence to facilitate secretion drainage, and oxygen should be administered via blow-by at 3 liters per minute.
In the post-anesthesia care unit (PACU), airway patency and stable oxygen saturation above 94 percent should be confirmed immediately upon arrival. At 15 minutes, pain should be well controlled, ideally with a FLACC score below 4, and bleeding should be minimal. Fentanyl may be administered at 0.5 micrograms per kg as needed. After 30 minutes, patients should tolerate oral fluids without retching. At 60 minutes, discharge may be considered if the patient has an Aldrete score of 9 or higher and can ambulate to a chair.
Children under three years of age, those with high PSQ scores, or those diagnosed with OSA should be observed for a minimum of four hours before discharge.
Parents should be advised that red-tinged saliva is expected postoperatively, but any bright red blood exceeding one teaspoon warrants emergency evaluation. Caregivers must ensure the child maintains hydration at a minimum of two ounces of water per hour. The prescribed pain regimen should include weight-based acetaminophen administered around the clock, with ibuprofen added after 24 hours unless contraindicated by the surgeon.
A visual aid, such as a refrigerator magnet listing warning signs of postoperative bleeding, should be provided for easy reference.
Key outcome metrics include an unplanned admission rate below 2 percent, a return-to-emergency rate for bleeding under 3 percent within seven days, and a postoperative nausea and vomiting (PONV) rate under 15 percent. Emergence agitation should also be tracked using FLACC scores, with spikes above seven flagged for review. Monthly team debriefs can drive protocol improvements based on these data.
Pediatric tonsillectomy in the ASC setting can be both safe and effective when guided by a structured safety checklist that covers screening, intraoperative management, and postoperative care. Collaboration with CRNAs experienced in pediatric ENT anesthesia further enhances patient safety, improves efficiency, and supports consistent discharge outcomes.
Advanced Anesthesia Services provides board-certified CRNAs with pediatric expertise, ready to integrate into your ASC workflow and scale with seasonal or volume-based fluctuations.
