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Day-case tonsillectomy in children: parental attitudes and consultation rates
International Journal of Pediatric Otorhinolaryngology (2003) 67, 777 /784
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Day-case tonsillectomy in children: parental attitudes and consultation rates ¨rantac,2 Mervi Kanervaa,*, Pekka Tarkkilab,1, Anne Pitka a
Department of Otorhinolaryngology, University Hospital of Helsinki, POB 220, FIN-00029 Hus, Finland Anesthesia and Intensive Care, University Hospital of Helsinki, POB 220, FIN-00029 Hus, Finland c Department of Otorhinolaryngology, University Hospital of Helsinki, POB 220, FIN-00029 Hus, Finland b
Received 14 November 2002; received in revised form 2 March 2003; accepted 3 March 2003
KEYWORDS Day-case tonsillectomy; Pediatric tonsillectomy; Parental attitudes; Consultation rates
Summary Objective: In Europe, the day-case tonsillectomy rate in children is slowly increasing, but whether parents really want this rapid discharge of their child is questionable. The fear is that aftercare might fall solely on community care. The aim of this prospective study was to introduce pediatric day-case tonsillectomy to our hospital and to determine parents’ attitudes to this procedure. The other interest centered on consultation rates within the 2-week recovery period. Methods: One hundred children aged 3 /16 years had day-case tonsillectomy (38) or adenotonsillectomy (62). Peri-operative and post-operative complications were recorded. Parents were phoned the next day and 1 /4 months after the operation. Parents’ opinions of day-case surgery and consultations with healthcare professionals during the 2-week recovery period were recorded. Results: Ninety children went home the day of the operation. Vomiting was the most frequent complication. No primary hemorrhages occurred. Called the next day, 100% of parents felt that their children were better served spending their first night at home as compared with staying in hospital. Called 1 /4 months later, 94.5% of parents still thought this way. In the 2week recovery period following the tonsillectomy, 13% of patients visited a physician and 17% called for information. These numbers include patients with secondary hemorrhage. If these are excluded, 5% of patients visited a physician and 13% called for advice. Children were taken back to hospital only due to secondary hemorrhage. Conclusions: Most parents considered day-case tonsillectomy to be suitable for their family. Consultation rates were low. Careful patient selection and adequate preoperative information are prerequisites for day-case tonsillectomy. – 2003 Elsevier Science Ireland Ltd. All rights reserved.
1. Introduction *Corresponding author. Tel.: /358-9-4716-2090; fax: /3589-4717-5010. E-mail addresses: [email protected] (M. Kanerva), [email protected] (P. Tarkkila), [email protected] (A. Pitka ¨ranta). 1 Tel.: /358-50-4272136; fax: /358-9-4717-6024. 2 Tel.: /358-50-4272559; fax: /358-9-4717-5010.
In Helsinki University Hospital in Finland, tonsillectomies have traditionally been done in inpatient settings. However, a new day-case surgical ward was under construction when this study was carried out. In the United States, day-case tonsillectomies are done at least in part for financial reasons and
0165-5876/03/$ - see front matter – 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0165-5876(03)00097-1
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because of pressure from insurance companies. Riding et al. in Canada have reported that day-case tonsillectomies have increased in popularity because of the decreasing availability of hospital beds and growing waiting lists [1]. In Europe, the daycase tonsillectomy rate is slowly increasing, but in some districts patients still spend several nights in hospital [2]. However, the stress experienced by children may be less in day-case operations than in inpatient settings [3]. The information given to the child and parents is very important [4]. We rewrote all of our pre- and post-operative instructions. We also simplified diet instructions; the patient may return to a normal diet the day after the operation. Besides introducing pediatric day-case tonsillectomy to our hospital, our goals included determination of parental attitudes and how they managed the first 24 h post-operatively at home with their child. During the 2-week recovery period we recorded all contacts with healthcare personnel, which provided an idea of how the families were doing and whether information given to them was sufficient.
2. Patients and methods One hundred children underwent day-case tonsillectomy or adenotonsillectomy between September and November 2000 in the otorhinolaryngology (ENT) department of Helsinki University Hospital, Finland. The children were from the normal operation waiting list and selected to be suitable for daycase surgery by a senior doctor of the ward. Patients were between 3 and 16 years of age. Children with underlying medical conditions requiring constant medication and those at high risk for obstructive sleep apnea syndrome (OSAS) were excluded. If a child had pneumonia, 1 month was required from the recovery before the operation. Parents had to be cooperative. Maximum driving time from home to hospital was set at 1 h. A total of 46 girls and 54 boys were operated on. The mean age was 7.7 (2.7 /16.7) years. Thirtyeight tonsillectomies and 62 adenotonsillectomies were performed. Indications for operation are presented in Table 1. Additional otomicroscopy was done for 29 children (18 with parasenthesis or grommets), two needed frenulotomy, and another two coagulation of a bleeding vessel from the nose. One child had a bronchoscopy. The same resident operated on all the children. Tonsillectomies were done with a cold dissection method, and hemostasis with packing and bipolar diathermy.
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Table 1 Indications for day-case (adeno-) tonsillectomy in children Indicationa
Number of patients
Snoring Chronic tonsillitis Tonsillar hypertrophy Tonsillar and adenoidal hypertrophy Adenoidal hypertrophy Peritonsillar abscess in history Bite disorder Cyclic fever Cough
74 38 37 52
a
1 4 5 2 1
Often more than one indication per child.
Patients came to the ward on the morning of the operation. The operating physician examined each child and discussed the details of the operation with the child and parents. Families had received pre- and post-operative care instructions beforehand by mail. All questions were answered. During the operation children received diclofenac and tramadol intravenously. Metoclopramide was used to prevent vomiting and emesis. A subcutaneous needle was inserted for pain medication. Oxycodone was used intravenously in the recovery room and subcutaneously in the ward after the operation. One hour before going home, children were administered diclofenac 1 mg/kg intravenously. Children were kept a few hours in the recovery room and then returned to the ward. The operating physician met the child and parents in the ward after the operation, and care instructions, possible complications, and medication were discussed. Pain medication at home was naproxen 10 mg/ kg/24 h and acetaminophen 60 mg/kg/24 h for children under 10 years. Children over 10 years received naproxen 10 mg/kg/24 h or ketoprofen 5 mg/kg/24 h as well as acetaminophen combined with codeine (dose counted from acetaminophen 60 mg/kg/24 h, the tablet containing 500 mg acetaminophen and 30 mg codeine). After a few days, the acetaminophen and codeine combination could be changed to acetaminophen alone. Regular use of pain medication for at least 1 week was recommended. Metoclopramide suppositories were prescribed for emesis and vomiting. A ward nurse sent children home when discharge criteria were met (Table 2). The operating physician called the parents the day after the operation to determine how the time at home had gone and what the parents thought about day-case tonsillectomy (Table 3).
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Table 2 Day-case discharge criteria
3. Results
Minimum 6-h post-operative stay Patient drinking/eating Pain controlled with medication Minimal nausea No vomiting for an hour Alert and oriented Mobile Adult companion if parent driving home Parent/child have received Oral instructions Written instructions Information on pain medication Contact phone numbers
The mean observation period at the hospital was slightly less than 8 h. Ninety patients of a hundred went home on the day of the operation. Ten children stayed in hospital overnight, five of them because of vomiting. None of these patients vomited more than four times. Altogether 61% of the children vomited after the operation. Every vomiting incident from the recovery room to the next day at home was counted. The proportion of patients vomiting once or twice was 31% and more than four times 9%. Vomiting was more common in adenotonsillectomy than in tonsillectomy (71 vs. 45%, P /0.009, x2). Nobody vomited beyond 12 h post-operation. One child received a large dose of oxycodone in the recovery room and was observed overnight in the ward. Also kept overnight were two children who had excessive bleeding during the operation and one child with suspected sleep apnea. The latter child’s oxygen saturation was monitored and values were consistently normal. One child stayed for social reasons. Every child staying overnight in hospital was fine on observation and was discharged the next day.
In January 2001, 1 /4 months after the tonsillectomy, the operating physician called the parents a second time to inquire about the 2-week recovery period after the operation and whether the family had contacted any healthcare professionals. Those parents whose child (N /90) went home the day of the operation were asked again how they felt about day-case tonsillectomy. The study protocol was accepted by the local ethical committee.
Table 3 Contact call to parents the day after the operation (N /90)
The child: Was able to drink or eat on the day of the operation at home Was able to drink or eat the next morning Slept well the first night Woke up during the night because of pain Has started to play normally Nausea Vomiting Bleeding from nose Bleeding from mouth Has urinated Would it have been better to stay at the hospital the first night? Did you receive enough information about the operation? Did you receive enough information about pain and nausea medication? Do you know who to contact if advice needed? Did the pre- and post-operative written instructions give you enough information? Opinion on your child’s pain on a scale from 0 to 10 (0, painless; 10, worst possible pain) Mean 3.5 Median 3.75 Based on your experience, how easy/difficult was the first night on a scale from 0 to 10? (0, very easy; 10, worst possible) Mean 2.3 Median 1.5 a b
Nine percent continued regular sleep after receiving a dose of pain medication. Once 25 children, twice seven children, three times four children, four times one child.
Yes (%)
No (%)
82 100 71 38a 62 17 41b 0 0 100 0 100 100 100 100
18 0 29 62 38 83 59 100 100 0 100 0 0 0 0
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The day after the operation, the operating physician called those parents whose child went home on the day of the operation (Table 3). Some parents stated that their child had slept well the first night at home, even though the child had woken up during the night because of pain. They explained that regular sleep resumed after administration of pain medication. The parents generally felt that the first night at home had been easy. No primary hemorrhages (within 24 h of the operation) occurred. However, five secondary hemorrhages (over 24 h from the operation) were sustained, requiring hemostasis done under general or local anesthesia. Moreover, three children had bled, but when they arrived at the emergency room, the bleeding had stopped and no actions needed to be taken. When parents were called 1 /4 months after the operation, we found that four children had had bleeding at home and their parents had called the nurse at the emergency room. The bleeding had been of short duration, stopping spontaneously, and no visit to a doctor had been necessary. An additional three children had had so little bleeding at home that their parents did not contact anyone. Altogether 15 children had bled in the 2-week recovery period if even a bit of red seen in saliva is counted. Only children with secondary hemorrhages had to be taken back to hospital after discharge. In the 2-week recovery period, five children had seen their general practitioner or a private doctor. Two of these children had an earache and one had fever; these three were the only ones of the 100 patients to be prescribed antibiotics. Two children were seen because they ate poorly, but their condition improved after the visit to the doctor, and no specific actions were taken. Five children under 10 years needed extra medication for pain and their parents called for a prescription. They got better within a few days of taking extra tramadol medication. Eight parents had called a doctor or a nurse for some other advice. Altogether 13% of the 100 children operated on had visited a doctor and the parents of 17% had called healthcare personnel (these numbers include those patients with secondary hemorrhage). One day after the operation, all parents whose children (N /90) went home the day of the operation thought that spending the first night at home was better than staying in hospital would have been. When asked again 1 /4 months later, five parents had changed their mind: 94.5% still approved of day-case surgery, 5.5% would have preferred that their child spend one night in hospital following the procedure.
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4. Discussion Since it appears that day-case tonsillectomy is safe and parents gladly take care of their child at home the first night after the operation, why not perform day-case surgery? If it even brings financial savings, what would be better?
4.1. Primary hemorrhages The safety of tonsillectomy is mostly judged according to the risk for primary hemorrhage. Its occurrence is estimated between 0 and 3.5% of tonsillectomies [4 /11], although its definition varies. Primary hemorrhage may be more serious than secondary bleeding since it usually occurs when the patient’s responsiveness and protective airway reflexes are blunted by post-anesthetic or narcotic effects [12]. Primary hemorrhage can also be more rapid and profuse than secondary hemorrhage [12]. Numerous studies have discussed the minimum observation period needed after the procedure. Most primary hemorrhages occur within 6 /8 h of the operation [4,7,8,10,11,13]. However, even shorter observation periods have been considered to be safe [14 /18]. We had no primary hemorrhages in our study.
4.2. Secondary hemorrhages It is very hard to interpret the occurrences of secondary hemorrhage reported in the literature because the criteria vary markedly. In some studies, only hemorrhages treated under general anesthesia are counted. Secondary hemorrhage rates as low as 0% have been published [15], in contrast to the 32.8% reported in adult patient tonsillectomies [19]. Results based on patient questionnaires also include minor bleedings with no actions taken and reveal higher, perhaps more truthful, hemorrhage percentages [19 /21]. In our study, eight children came to the emergency room because of secondary hemorrhages. An operation to achieve hemostasis was performed on five of them. In addition, seven children had minor bleeding at home. The number of secondary hemorrhage patients needing an operation was consistent with our prior experience of inpatient pediatric tonsillectomies.
4.3. Age and pre-existing medical conditions Selection criteria of patients are essential to ensure the safety and success of day-case tonsil-
Day-case tonsillectomy in children: parental attitudes and consultation rates
lectomy. Children under 3 years are generally considered to be unsuitable for day-case surgery because of the higher risk for complications [9,15,22 /25]. Nevertheless, in some studies, children under 3 years have managed as well as older children [11,26]. We had a minimum cut-off age of 3 years. This being a preliminary study, children with obvious and severe symptoms of OSAS were excluded. Children with a history of habitual snoring and co-existing tonsillar hypertrophy without other obvious manifestations of upper airway resistance syndrome (UARS) or OSAS were operated on without pre-operative evaluation of their sleeping disorder. Snoring was the most frequent indication for surgery, thus, milder cases of sleeping disorders were included. Habitual snorers were not differentiated from occasional snorers.
4.4. Operating physician No noticeable differences in success or complication rates have been reported when comparing tonsillectomies done by specialists and residents [6,8,27].
4.5. Information It is very important that children and parents are well informed in advance of day-case tonsillectomy [3,4,28]. We rewrote all of our information sheets to ensure that children and parents knew exactly what was going to happen at the hospital, what complications might follow the operation, and what actions should then be taken. Oral information at the ward also received special attention. When asked the day following the procedure, all parents replied that they had received sufficient spoken and written information and that they knew who to contact in case of a complication or if they needed advice. Bartley and Connew [29] suggested that nursing staff receive more reliable answers than medical staff members when assessing levels of postoperative discomfort and patient satisfaction. To minimize this bias we asked parents not to be polite but truthful because we were building up a practice for day-case tonsillectomies and parents’ opinions would directly affect the way we would act in the future.
4.6. Consultations In Denmark, a study [30] of consultations with healthcare professionals after inpatient tonsillectomies/adenotonsillectomies was conducted. The
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consultation rate was suggested to be a parameter of quality of both treatment and information. Consultations in person and by phone were included. Of those operated on, 47% contacted a healthcare professional within the 12-day followup. The main reason for a consultation was pain. In their study in England and Wales (mostly inpatient tonsillectomies), Faulconbridge et al. [20] reported a consultation rate of 62% with a general practitioner and 26% for out-of-hours advice from either an emergency general practitioner, ENT department, or other. Lee and Sharp [21] counted only consultation visits to a general practitioner within 5 days of inpatient pediatric tonsillectomy and still 60.6% of patients/their parents required consultation. Jones et al. [31] also reported only visits to a general practitioner after inpatient pediatric tonsillectomy: first 41% and after a change in management 28% visited. Homer et al. [32] reported 50% of the families consulting their general practitioner after inpatient pediatric tonsillectomy mainly because of pain. When pain medication and written discharge advice were improved, the consultations dropped to 27%. Bartley and Connew [29] reported 30% parental contacts with a general practitioner in addition to contacts with the day stay unit in pediatric day-case tonsillectomy. We counted all contacts with healthcare professionals by phone or in person within a 2-week period of discharge: 13% visited a doctor and 17% called for advice. When patients with secondary hemorrhage are excluded, 5% visited a doctor and 13% called for advice. Day-case tonsillectomy did not put the load of aftercare on community care, as is often feared [33,34]. Adequate information presumably kept consultation rates fairly low.
4.7. Vomiting Vomiting is common after tonsillectomy [9,35], but the findings vary. In some studies, only 0.7 / 2.5% of patients vomited after tonsillectomy [10,16], but 30 /55% is more common [9,36,37]. In studies conducted by anesthesiologists, figures are even higher [38,39]. The etiology of post-operative vomiting is probably multifactorial: swallowed blood, pain, opiate administration, direct oropharyngeal irritation, and history of motion sickness are considered to affect the incidence of post-operative vomiting [17,35]. In some studies, only prolonged vomiting was counted and its definition varied. In other studies, every vomiting incident was counted, as in ours. In all, 61% of children vomited. Children with adenotonsillectomy vomited more often than those
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with tonsillectomy. Some of the children vomited at home on the day of the operation. Since parents were informed of the frequency of post-operative vomiting, they responded calmly and tolerated it well. Vomiting was the most frequent complication in our study. Previously, Hellier et al. [8] also reported vomiting as their greatest complication in a series of 928 patients.
4.8. Pain medication Regular post-operative pain treatment after tonsillectomy has advantages compared with ondemand medication [40,41]. In Finland, nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used as peri- and post-operative medication in tonsillectomies. While they prolong bleeding time, the clinical significance of this is controversial. Judkins et al. [42] recommended that the use of ketorolac in patients undergoing tonsillectomy be avoided because of the increased incidence of post-operative bleeding complications. However, in some other studies, no increased risk for postoperative hemorrhages was present with the use of NSAIDs [32,41,43 /45]. New, larger studies are needed to further evaluate this question [46,47]. Sometimes parents give less pain medication to their child than advised because they are afraid of side-effects and possible addiction [48]. We emphasized the importance of a regular and sufficiently long course of pain medication both in written and oral information to the patients and parents. We also encouraged the parents to call us if the medication was inadequate. Swedish experts on child pain medication found the opinion of the child to be missing from most studies investigating children’s pain [49]. We asked parents to grade their child’s pain and they considered it to be quite low (Table 3). Possibly, if we had asked the children, the answers might have been different. However, our goal was to find out how parents felt they managed the first night at home and how they experienced their child’s pain. Obviously, the child’s point of view is also very important. Overall, parents felt that the pain of their child was treated well with the medication prescribed. Five children under 10 years needed additional medication (tramadol) for a few days.
4.9. Follow-up If day-case tonsillectomies are to be done, we need to know how children and parents manage at home [29]. Studies examining this are limited [14,29,37,50]. Based on the answers of the parents in our study, both children and parents did well at
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home. The first night at home after the operation was apparently quite easy (Table 3).
4.10. Parental attitudes Do parents want day-case tonsillectomies for their children? When this was asked of parents with no experience of day-case tonsillectomies (whose child was an inpatient), the answer was no [7,21,28,33,51]. When parents who have undergone the experience (whose child underwent daycase surgery and went home the day of the operation) were asked, the answer was yes, both beforehand and after the operation [1,8,18,29]. The importance of adequate information beforehand cannot be overstated. In day-case surgery, it is essential that both the child and parents have a positive attitude towards the procedure [37]. When asked the first day after the operation, 100% of parents whose child went home the day of the operation thought that the night at home was better than a hospital stay would have been. Fredelius et al. [37], in a similar study, found that 91% of parents preferred day-case tonsillectomy when asked the next day. When asked again 1 /4 months later, 94.5% of parents in our study maintained the same view: they would have chosen daycase tonsillectomy again. By contrast, in Fredelius et al., the number of parents choosing day-case tonsillectomy dropped to 70% [37].
5. Conclusions Most families considered day-case tonsillectomy to be suitable for their family. Consultation rates were rather low compared with other similar studies. Selecting the right patients and providing abundant information to children and families is essential.
Acknowledgements The authors thank the nursing staff at the ENT department of Helsinki University Hospital, especially Pirkko Torp and Irja Ja ¨ntti. Kirsti Salo, Head of the Department of Otorhinolaryngology, Peijas Hospital, Vantaa, Finland, is thanked for valuable collaboration in patient recruitment.
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www.elsevier.com/locate/ijporl
Day-case tonsillectomy in children: parental attitudes and consultation rates ¨rantac,2 Mervi Kanervaa,*, Pekka Tarkkilab,1, Anne Pitka a
Department of Otorhinolaryngology, University Hospital of Helsinki, POB 220, FIN-00029 Hus, Finland Anesthesia and Intensive Care, University Hospital of Helsinki, POB 220, FIN-00029 Hus, Finland c Department of Otorhinolaryngology, University Hospital of Helsinki, POB 220, FIN-00029 Hus, Finland b
Received 14 November 2002; received in revised form 2 March 2003; accepted 3 March 2003
KEYWORDS Day-case tonsillectomy; Pediatric tonsillectomy; Parental attitudes; Consultation rates
Summary Objective: In Europe, the day-case tonsillectomy rate in children is slowly increasing, but whether parents really want this rapid discharge of their child is questionable. The fear is that aftercare might fall solely on community care. The aim of this prospective study was to introduce pediatric day-case tonsillectomy to our hospital and to determine parents’ attitudes to this procedure. The other interest centered on consultation rates within the 2-week recovery period. Methods: One hundred children aged 3 /16 years had day-case tonsillectomy (38) or adenotonsillectomy (62). Peri-operative and post-operative complications were recorded. Parents were phoned the next day and 1 /4 months after the operation. Parents’ opinions of day-case surgery and consultations with healthcare professionals during the 2-week recovery period were recorded. Results: Ninety children went home the day of the operation. Vomiting was the most frequent complication. No primary hemorrhages occurred. Called the next day, 100% of parents felt that their children were better served spending their first night at home as compared with staying in hospital. Called 1 /4 months later, 94.5% of parents still thought this way. In the 2week recovery period following the tonsillectomy, 13% of patients visited a physician and 17% called for information. These numbers include patients with secondary hemorrhage. If these are excluded, 5% of patients visited a physician and 13% called for advice. Children were taken back to hospital only due to secondary hemorrhage. Conclusions: Most parents considered day-case tonsillectomy to be suitable for their family. Consultation rates were low. Careful patient selection and adequate preoperative information are prerequisites for day-case tonsillectomy. – 2003 Elsevier Science Ireland Ltd. All rights reserved.
1. Introduction *Corresponding author. Tel.: /358-9-4716-2090; fax: /3589-4717-5010. E-mail addresses: [email protected] (M. Kanerva), [email protected] (P. Tarkkila), [email protected] (A. Pitka ¨ranta). 1 Tel.: /358-50-4272136; fax: /358-9-4717-6024. 2 Tel.: /358-50-4272559; fax: /358-9-4717-5010.
In Helsinki University Hospital in Finland, tonsillectomies have traditionally been done in inpatient settings. However, a new day-case surgical ward was under construction when this study was carried out. In the United States, day-case tonsillectomies are done at least in part for financial reasons and
0165-5876/03/$ - see front matter – 2003 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0165-5876(03)00097-1
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because of pressure from insurance companies. Riding et al. in Canada have reported that day-case tonsillectomies have increased in popularity because of the decreasing availability of hospital beds and growing waiting lists [1]. In Europe, the daycase tonsillectomy rate is slowly increasing, but in some districts patients still spend several nights in hospital [2]. However, the stress experienced by children may be less in day-case operations than in inpatient settings [3]. The information given to the child and parents is very important [4]. We rewrote all of our pre- and post-operative instructions. We also simplified diet instructions; the patient may return to a normal diet the day after the operation. Besides introducing pediatric day-case tonsillectomy to our hospital, our goals included determination of parental attitudes and how they managed the first 24 h post-operatively at home with their child. During the 2-week recovery period we recorded all contacts with healthcare personnel, which provided an idea of how the families were doing and whether information given to them was sufficient.
2. Patients and methods One hundred children underwent day-case tonsillectomy or adenotonsillectomy between September and November 2000 in the otorhinolaryngology (ENT) department of Helsinki University Hospital, Finland. The children were from the normal operation waiting list and selected to be suitable for daycase surgery by a senior doctor of the ward. Patients were between 3 and 16 years of age. Children with underlying medical conditions requiring constant medication and those at high risk for obstructive sleep apnea syndrome (OSAS) were excluded. If a child had pneumonia, 1 month was required from the recovery before the operation. Parents had to be cooperative. Maximum driving time from home to hospital was set at 1 h. A total of 46 girls and 54 boys were operated on. The mean age was 7.7 (2.7 /16.7) years. Thirtyeight tonsillectomies and 62 adenotonsillectomies were performed. Indications for operation are presented in Table 1. Additional otomicroscopy was done for 29 children (18 with parasenthesis or grommets), two needed frenulotomy, and another two coagulation of a bleeding vessel from the nose. One child had a bronchoscopy. The same resident operated on all the children. Tonsillectomies were done with a cold dissection method, and hemostasis with packing and bipolar diathermy.
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Table 1 Indications for day-case (adeno-) tonsillectomy in children Indicationa
Number of patients
Snoring Chronic tonsillitis Tonsillar hypertrophy Tonsillar and adenoidal hypertrophy Adenoidal hypertrophy Peritonsillar abscess in history Bite disorder Cyclic fever Cough
74 38 37 52
a
1 4 5 2 1
Often more than one indication per child.
Patients came to the ward on the morning of the operation. The operating physician examined each child and discussed the details of the operation with the child and parents. Families had received pre- and post-operative care instructions beforehand by mail. All questions were answered. During the operation children received diclofenac and tramadol intravenously. Metoclopramide was used to prevent vomiting and emesis. A subcutaneous needle was inserted for pain medication. Oxycodone was used intravenously in the recovery room and subcutaneously in the ward after the operation. One hour before going home, children were administered diclofenac 1 mg/kg intravenously. Children were kept a few hours in the recovery room and then returned to the ward. The operating physician met the child and parents in the ward after the operation, and care instructions, possible complications, and medication were discussed. Pain medication at home was naproxen 10 mg/ kg/24 h and acetaminophen 60 mg/kg/24 h for children under 10 years. Children over 10 years received naproxen 10 mg/kg/24 h or ketoprofen 5 mg/kg/24 h as well as acetaminophen combined with codeine (dose counted from acetaminophen 60 mg/kg/24 h, the tablet containing 500 mg acetaminophen and 30 mg codeine). After a few days, the acetaminophen and codeine combination could be changed to acetaminophen alone. Regular use of pain medication for at least 1 week was recommended. Metoclopramide suppositories were prescribed for emesis and vomiting. A ward nurse sent children home when discharge criteria were met (Table 2). The operating physician called the parents the day after the operation to determine how the time at home had gone and what the parents thought about day-case tonsillectomy (Table 3).
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Table 2 Day-case discharge criteria
3. Results
Minimum 6-h post-operative stay Patient drinking/eating Pain controlled with medication Minimal nausea No vomiting for an hour Alert and oriented Mobile Adult companion if parent driving home Parent/child have received Oral instructions Written instructions Information on pain medication Contact phone numbers
The mean observation period at the hospital was slightly less than 8 h. Ninety patients of a hundred went home on the day of the operation. Ten children stayed in hospital overnight, five of them because of vomiting. None of these patients vomited more than four times. Altogether 61% of the children vomited after the operation. Every vomiting incident from the recovery room to the next day at home was counted. The proportion of patients vomiting once or twice was 31% and more than four times 9%. Vomiting was more common in adenotonsillectomy than in tonsillectomy (71 vs. 45%, P /0.009, x2). Nobody vomited beyond 12 h post-operation. One child received a large dose of oxycodone in the recovery room and was observed overnight in the ward. Also kept overnight were two children who had excessive bleeding during the operation and one child with suspected sleep apnea. The latter child’s oxygen saturation was monitored and values were consistently normal. One child stayed for social reasons. Every child staying overnight in hospital was fine on observation and was discharged the next day.
In January 2001, 1 /4 months after the tonsillectomy, the operating physician called the parents a second time to inquire about the 2-week recovery period after the operation and whether the family had contacted any healthcare professionals. Those parents whose child (N /90) went home the day of the operation were asked again how they felt about day-case tonsillectomy. The study protocol was accepted by the local ethical committee.
Table 3 Contact call to parents the day after the operation (N /90)
The child: Was able to drink or eat on the day of the operation at home Was able to drink or eat the next morning Slept well the first night Woke up during the night because of pain Has started to play normally Nausea Vomiting Bleeding from nose Bleeding from mouth Has urinated Would it have been better to stay at the hospital the first night? Did you receive enough information about the operation? Did you receive enough information about pain and nausea medication? Do you know who to contact if advice needed? Did the pre- and post-operative written instructions give you enough information? Opinion on your child’s pain on a scale from 0 to 10 (0, painless; 10, worst possible pain) Mean 3.5 Median 3.75 Based on your experience, how easy/difficult was the first night on a scale from 0 to 10? (0, very easy; 10, worst possible) Mean 2.3 Median 1.5 a b
Nine percent continued regular sleep after receiving a dose of pain medication. Once 25 children, twice seven children, three times four children, four times one child.
Yes (%)
No (%)
82 100 71 38a 62 17 41b 0 0 100 0 100 100 100 100
18 0 29 62 38 83 59 100 100 0 100 0 0 0 0
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The day after the operation, the operating physician called those parents whose child went home on the day of the operation (Table 3). Some parents stated that their child had slept well the first night at home, even though the child had woken up during the night because of pain. They explained that regular sleep resumed after administration of pain medication. The parents generally felt that the first night at home had been easy. No primary hemorrhages (within 24 h of the operation) occurred. However, five secondary hemorrhages (over 24 h from the operation) were sustained, requiring hemostasis done under general or local anesthesia. Moreover, three children had bled, but when they arrived at the emergency room, the bleeding had stopped and no actions needed to be taken. When parents were called 1 /4 months after the operation, we found that four children had had bleeding at home and their parents had called the nurse at the emergency room. The bleeding had been of short duration, stopping spontaneously, and no visit to a doctor had been necessary. An additional three children had had so little bleeding at home that their parents did not contact anyone. Altogether 15 children had bled in the 2-week recovery period if even a bit of red seen in saliva is counted. Only children with secondary hemorrhages had to be taken back to hospital after discharge. In the 2-week recovery period, five children had seen their general practitioner or a private doctor. Two of these children had an earache and one had fever; these three were the only ones of the 100 patients to be prescribed antibiotics. Two children were seen because they ate poorly, but their condition improved after the visit to the doctor, and no specific actions were taken. Five children under 10 years needed extra medication for pain and their parents called for a prescription. They got better within a few days of taking extra tramadol medication. Eight parents had called a doctor or a nurse for some other advice. Altogether 13% of the 100 children operated on had visited a doctor and the parents of 17% had called healthcare personnel (these numbers include those patients with secondary hemorrhage). One day after the operation, all parents whose children (N /90) went home the day of the operation thought that spending the first night at home was better than staying in hospital would have been. When asked again 1 /4 months later, five parents had changed their mind: 94.5% still approved of day-case surgery, 5.5% would have preferred that their child spend one night in hospital following the procedure.
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4. Discussion Since it appears that day-case tonsillectomy is safe and parents gladly take care of their child at home the first night after the operation, why not perform day-case surgery? If it even brings financial savings, what would be better?
4.1. Primary hemorrhages The safety of tonsillectomy is mostly judged according to the risk for primary hemorrhage. Its occurrence is estimated between 0 and 3.5% of tonsillectomies [4 /11], although its definition varies. Primary hemorrhage may be more serious than secondary bleeding since it usually occurs when the patient’s responsiveness and protective airway reflexes are blunted by post-anesthetic or narcotic effects [12]. Primary hemorrhage can also be more rapid and profuse than secondary hemorrhage [12]. Numerous studies have discussed the minimum observation period needed after the procedure. Most primary hemorrhages occur within 6 /8 h of the operation [4,7,8,10,11,13]. However, even shorter observation periods have been considered to be safe [14 /18]. We had no primary hemorrhages in our study.
4.2. Secondary hemorrhages It is very hard to interpret the occurrences of secondary hemorrhage reported in the literature because the criteria vary markedly. In some studies, only hemorrhages treated under general anesthesia are counted. Secondary hemorrhage rates as low as 0% have been published [15], in contrast to the 32.8% reported in adult patient tonsillectomies [19]. Results based on patient questionnaires also include minor bleedings with no actions taken and reveal higher, perhaps more truthful, hemorrhage percentages [19 /21]. In our study, eight children came to the emergency room because of secondary hemorrhages. An operation to achieve hemostasis was performed on five of them. In addition, seven children had minor bleeding at home. The number of secondary hemorrhage patients needing an operation was consistent with our prior experience of inpatient pediatric tonsillectomies.
4.3. Age and pre-existing medical conditions Selection criteria of patients are essential to ensure the safety and success of day-case tonsil-
Day-case tonsillectomy in children: parental attitudes and consultation rates
lectomy. Children under 3 years are generally considered to be unsuitable for day-case surgery because of the higher risk for complications [9,15,22 /25]. Nevertheless, in some studies, children under 3 years have managed as well as older children [11,26]. We had a minimum cut-off age of 3 years. This being a preliminary study, children with obvious and severe symptoms of OSAS were excluded. Children with a history of habitual snoring and co-existing tonsillar hypertrophy without other obvious manifestations of upper airway resistance syndrome (UARS) or OSAS were operated on without pre-operative evaluation of their sleeping disorder. Snoring was the most frequent indication for surgery, thus, milder cases of sleeping disorders were included. Habitual snorers were not differentiated from occasional snorers.
4.4. Operating physician No noticeable differences in success or complication rates have been reported when comparing tonsillectomies done by specialists and residents [6,8,27].
4.5. Information It is very important that children and parents are well informed in advance of day-case tonsillectomy [3,4,28]. We rewrote all of our information sheets to ensure that children and parents knew exactly what was going to happen at the hospital, what complications might follow the operation, and what actions should then be taken. Oral information at the ward also received special attention. When asked the day following the procedure, all parents replied that they had received sufficient spoken and written information and that they knew who to contact in case of a complication or if they needed advice. Bartley and Connew [29] suggested that nursing staff receive more reliable answers than medical staff members when assessing levels of postoperative discomfort and patient satisfaction. To minimize this bias we asked parents not to be polite but truthful because we were building up a practice for day-case tonsillectomies and parents’ opinions would directly affect the way we would act in the future.
4.6. Consultations In Denmark, a study [30] of consultations with healthcare professionals after inpatient tonsillectomies/adenotonsillectomies was conducted. The
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consultation rate was suggested to be a parameter of quality of both treatment and information. Consultations in person and by phone were included. Of those operated on, 47% contacted a healthcare professional within the 12-day followup. The main reason for a consultation was pain. In their study in England and Wales (mostly inpatient tonsillectomies), Faulconbridge et al. [20] reported a consultation rate of 62% with a general practitioner and 26% for out-of-hours advice from either an emergency general practitioner, ENT department, or other. Lee and Sharp [21] counted only consultation visits to a general practitioner within 5 days of inpatient pediatric tonsillectomy and still 60.6% of patients/their parents required consultation. Jones et al. [31] also reported only visits to a general practitioner after inpatient pediatric tonsillectomy: first 41% and after a change in management 28% visited. Homer et al. [32] reported 50% of the families consulting their general practitioner after inpatient pediatric tonsillectomy mainly because of pain. When pain medication and written discharge advice were improved, the consultations dropped to 27%. Bartley and Connew [29] reported 30% parental contacts with a general practitioner in addition to contacts with the day stay unit in pediatric day-case tonsillectomy. We counted all contacts with healthcare professionals by phone or in person within a 2-week period of discharge: 13% visited a doctor and 17% called for advice. When patients with secondary hemorrhage are excluded, 5% visited a doctor and 13% called for advice. Day-case tonsillectomy did not put the load of aftercare on community care, as is often feared [33,34]. Adequate information presumably kept consultation rates fairly low.
4.7. Vomiting Vomiting is common after tonsillectomy [9,35], but the findings vary. In some studies, only 0.7 / 2.5% of patients vomited after tonsillectomy [10,16], but 30 /55% is more common [9,36,37]. In studies conducted by anesthesiologists, figures are even higher [38,39]. The etiology of post-operative vomiting is probably multifactorial: swallowed blood, pain, opiate administration, direct oropharyngeal irritation, and history of motion sickness are considered to affect the incidence of post-operative vomiting [17,35]. In some studies, only prolonged vomiting was counted and its definition varied. In other studies, every vomiting incident was counted, as in ours. In all, 61% of children vomited. Children with adenotonsillectomy vomited more often than those
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with tonsillectomy. Some of the children vomited at home on the day of the operation. Since parents were informed of the frequency of post-operative vomiting, they responded calmly and tolerated it well. Vomiting was the most frequent complication in our study. Previously, Hellier et al. [8] also reported vomiting as their greatest complication in a series of 928 patients.
4.8. Pain medication Regular post-operative pain treatment after tonsillectomy has advantages compared with ondemand medication [40,41]. In Finland, nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used as peri- and post-operative medication in tonsillectomies. While they prolong bleeding time, the clinical significance of this is controversial. Judkins et al. [42] recommended that the use of ketorolac in patients undergoing tonsillectomy be avoided because of the increased incidence of post-operative bleeding complications. However, in some other studies, no increased risk for postoperative hemorrhages was present with the use of NSAIDs [32,41,43 /45]. New, larger studies are needed to further evaluate this question [46,47]. Sometimes parents give less pain medication to their child than advised because they are afraid of side-effects and possible addiction [48]. We emphasized the importance of a regular and sufficiently long course of pain medication both in written and oral information to the patients and parents. We also encouraged the parents to call us if the medication was inadequate. Swedish experts on child pain medication found the opinion of the child to be missing from most studies investigating children’s pain [49]. We asked parents to grade their child’s pain and they considered it to be quite low (Table 3). Possibly, if we had asked the children, the answers might have been different. However, our goal was to find out how parents felt they managed the first night at home and how they experienced their child’s pain. Obviously, the child’s point of view is also very important. Overall, parents felt that the pain of their child was treated well with the medication prescribed. Five children under 10 years needed additional medication (tramadol) for a few days.
4.9. Follow-up If day-case tonsillectomies are to be done, we need to know how children and parents manage at home [29]. Studies examining this are limited [14,29,37,50]. Based on the answers of the parents in our study, both children and parents did well at
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home. The first night at home after the operation was apparently quite easy (Table 3).
4.10. Parental attitudes Do parents want day-case tonsillectomies for their children? When this was asked of parents with no experience of day-case tonsillectomies (whose child was an inpatient), the answer was no [7,21,28,33,51]. When parents who have undergone the experience (whose child underwent daycase surgery and went home the day of the operation) were asked, the answer was yes, both beforehand and after the operation [1,8,18,29]. The importance of adequate information beforehand cannot be overstated. In day-case surgery, it is essential that both the child and parents have a positive attitude towards the procedure [37]. When asked the first day after the operation, 100% of parents whose child went home the day of the operation thought that the night at home was better than a hospital stay would have been. Fredelius et al. [37], in a similar study, found that 91% of parents preferred day-case tonsillectomy when asked the next day. When asked again 1 /4 months later, 94.5% of parents in our study maintained the same view: they would have chosen daycase tonsillectomy again. By contrast, in Fredelius et al., the number of parents choosing day-case tonsillectomy dropped to 70% [37].
5. Conclusions Most families considered day-case tonsillectomy to be suitable for their family. Consultation rates were rather low compared with other similar studies. Selecting the right patients and providing abundant information to children and families is essential.
Acknowledgements The authors thank the nursing staff at the ENT department of Helsinki University Hospital, especially Pirkko Torp and Irja Ja ¨ntti. Kirsti Salo, Head of the Department of Otorhinolaryngology, Peijas Hospital, Vantaa, Finland, is thanked for valuable collaboration in patient recruitment.
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