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Outpatient tonsillectomy and adenoidectomy: complications and recommendations
International Journal
of Pediatric Otorhinolaryngology 30 (1994) 115-122
ELSEVIER
Outpatient tonsillectomy and adenoidectomy: complications and recommendations-f M.D. Schloss*“, A.K.W. Tanb, B. Schlossb, T.L. Tewfikb “Department of Orolaryngology, McGill University, Canada bDepartment of Otolaryngology, Montreal Children’s Hospital, 2300 Tupper Street, Montreal. Que H3H IP3, Canada (Received
10 May 1993; revision
received
27 January
1994: accepted
29 January
1994)
Abstract
An example of cost-effective alternatives in medical care is the increasing use of out-patient surgery for those children requiring tonsillectomy, or tonsillectomy with adenoidectomy rather than an in-patient procedure. Two studies were carried out to answer questions about the complications, in addition to post-operative hemorrhage, and also the questions about the parental views and concerns relating to providing at-home care for their children following surgery. A triad, including recent history of upper airway infection, knife dissection technique, and increased intra-operative blood loss of 100 ml or more should be used to help identify the risk of post-operative hemorrhage. Keywords;
Tonsillectomy;
Tonsillectomy
with adenoidectomy;
Ambulatory
surgery; Electro-
cautery
1. Introduction In the face of increasing pressures to control growth in health-care expenditures as the costs of medical care continue to escalate, attention has focused on identifying cost-effective treatment alternatives in a wide range of clinical conditions. Accord* Corresponding author, tPresented at The Eastern Otological
Society
Section Meeting of The American Laryngological, Rhinological Inc., Grand Hyatt Hotel, New York, NY, 28-30 January 1993.
0165-5876/94/$07.00 0 1994 Elsevier SSDI 0165-5876(94)01029-W
Science
Ireland
Ltd. All rights reserved
and
116
M.D. Schloss et al. /Int.
J. Pediatr.
Olorhinolaryngol.
30 (1994)
115-122
ingly, Canadian medical professionals are increasingly being obliged to seek out less costly treatment approaches, to meet the limited resources available to provincial authorities responsible for overseeing local health-care funding programs. In many instances, studies have confirmed that the overall quality of patient care is not diminished by the substitution of therapeutic options demonstrated to represent cost-effective alternatives to more traditional approaches. One such example is the increasing ux of out-patient surgery for those children requiring tonsillectomy, or tonsillectomy with adenoidectomy (T&A), rather than an in-patient procedure. Most prospective evaluations of out-patient tonsillectomy and T&As that have analyzed post-surgical complications requiring hospital admission, most specifically bleeding, have concluded that such complications in patients whose surgery has been performed on an ambulatory basis are no more frequent than those hospitalized following surgery [3,7]. Thus, it has been accepted that adenotonsillectomy is both safe and cost-effective when done on an out-patient basis. Most studies have analyzed post-surgical bleeding to be the major complication requiring hospitalization. However, a review of the literature reveals little discussion or consideration of other complications that require medical attention or even re-admission. Little discussion or consideration has taken place in the literature on the issues confronting the surgeon and primary-care practitioner namely, the parents, and the impact on them and other family members of providing the necessary care for their child immediately post-operatively following these common surgical procedures. In view of the complications requiring post-surgical admission to the hospital and the emotional and financial burdens inevitably placed on the families of these patients, particularly over the first post-operative day, two studies were undertaken. The first study involved a retrospective review of all tonsillectomy and adenotonsillectomy patients over a lo-month period. This study intended to answer the following questions: (1) what are the complications in addition to post-operative hemorrhage; (2) are there any factors associated with these complications that can predict which patient should be admitted to the hospital; (3) what are future recommendations with regard to out-patient surgery for tonsillectomy or adenotonsillectomy? The second study was to investigate and evaluate parental views and concerns relating to providing at-home care for their children following tonsillectomy or adenotonsillectomy. 2. Materials and methods In the first study on complications, a retrospective chart analysis of 555 cases of tonsillectomy and adenotonsillectomy between June 1990 and March 1991 was carried out. The indications for tonsillectomy and adenotonsillectomy were hypertrophic-obstructive tonsils and adenoids interfering with breathing and/or swallowing or recurring episodes of acute tonsillitis and adenotonsillitis. Patient information was recorded and tabulated into a data management software program for ,analysis. The study comprised a review of each chart including the patient’s age, sex, detailed history, including pre-operative assessment, examination and type of operation, the technique (cautery or knife dissection), intra-operative blood loss, length of hospitalization (if admission required), complications and management.
M.D. Schloss et al. /Int. J. Pediatr. Otorhinolaryngol. 30 11994) 115-122
117
In the second study on parental concerns, a total of 49 patients and their families were involved. To evaluate the impact on parents and other family members of providing immediate post-operative care for the child a questionnaire was formulated which was presented to a random sample of parents whose children were scheduled for surgery between May 1988 and September 1988. During this period all patients were routinely hospitalized for the first post-operative night. Each participant completed the same questionnaire at the pre-operative visit, then immediately predischarge the morning following surgery and finally at the first physician postoperative visit. The selection criteria established in 1989 for ambulatory tonsillectomy and adenotonsillectomy included the following: (1) over the age of 3 years; (2) living within one hour’s travel from the hospital; (3) a negative history of obstructive sleep apnea or co-existing medical problems. Post-operatively, the patients were sent home if they met the following criteria: (1) 4 h spent in the recovery room; (2) no active bleeding; (3) no vomiting; (4) good oral intake; (5) alert mental status; (6) no evidence of hypoxia on Po2 monitoring. 3. Results 3.1. Study on post-operative complications The organization of the patients according to the scheduled type of procedure (in-patient vs. out-patient) is shown in Fig. 1. Of the 555 cases of tonsillectomy and adenotonsillectomy, 103 (19%) were scheduled for in-patient procedures. The remaining 452 cases (81%) were scheduled for ambulatory procedures. Of all the patients who underwent ambulatory surgery, 91 (20%) had at least one complication while the remaining 361 (80%) had an uneventful recovery without complication (Fig. 2). Within the group of patients who had complications, 17 (19%) required emergency room management only, the other 74 patients (SlO/) with complications
Fig. 1. Outpatient
tonsillectomy
and adenoidectomy:
organization
of patients.
118
M.D.
Schloss et al. /Int.
J. Pediatr.
Otorhinolaryngol.
30 (1994)
115-122
Fig. 2. Outpatient tonsillectomy and adenoidectomy: complication rate.
were either admitted on the day of surgery as unplanned admissions, or admitted later when complications occurred. 3.2. Technique of tonsillectomy When comparing the surgical techniques used, 282 scheduled out-patients (62%) were operated by the traditional knife dissection technique, while 170 patients (38%) received electro-cautery dissection. For the in-patients, 58 (56%) underwent knife dissection. 3.3. Intra-operative blood loss For the scheduled out-patients, those that underwent knife dissection averaged 68 ml blood loss. The patients who underwent electro-cautery dissection averaged 26 ml blood loss. The data for the in-patient group was similar with knife dissection averaging 57 ml and the electro-cautery dissection technique averaging 20 ml. 3.4. Complications The complications encountered during and most commonly following tonsillectomy and adenotonsillectomy are shown in Table 1. Table 1 Outpatient tonsillectomy and adenoidectomy Complications Intra-operative hemorrhage Post-operative hemorrhage Aerodigestive tract (ADT) complications
M.D.
Schfoss et al. / Int.
J. Pediatr.
Otorhinolaryngol.
30 (1994)
115-122
119
3.5. Intra-operative hemorrhage
Intra-operative hemorrhage is defined as intra-operative blood loss of more than 5% body weight of the patient. Less than 1% (3) of all scheduled out-patients had this complication. The three patients underwent knife dissection technique for tonsillectomy and the average blood loss was 225 ml (4 x the average). All three patients were admitted post-operatively. No scheduled in-patient had an intra-operative hemorrhage. 3.6. Post-operative hemorrhage (POH) Primary post-operative hemorrhage is generally defined as hemorrhage from the operative site occurring within 24 h of surgery. Secondary hemorrhage occurs after the initial 24 h period. 3.7. Primary POH Of the scheduled out-patient population (452) 16 patients (3.5%) had a primary POH; however, only 4 (0.9%) required re-operation for control of hemorrhage. All were admitted post-operatively for observation, rehydration and antibiotics. For the scheduled in-patient group (103), two (1.9%) suffered primary POH with one patient requiring re-operation. 3.8. Secondary POH Twenty-three (5.1%) of the scheduled out-patients were complicated with secondary POH. Of these 23 patients, 19 (4.2%) were re-admitted with 4 of them requiring re-operation for hemostasis. The other 4 patients with secondary POH required emergency room management (rehydration with or without intravenous route observation and oral antibiotics) only. For those admitted, all received intravenous rehydration and antibiotics. For the scheduled in-patient population, two (1.9%) suffered secondary POH. None required management in the operating room. 3.9. Aerodigestive tract complications (ADT) This group of complications includes nausea, vomiting, dysphagia and any respiratory problem requiring medical attention. Forty-four of the scheduled out-patients (10%) required admission. Most of them were admitted immediately post-operatively as unplanned admissions or on the first post-operative day. Thirteen patients (3%) were treated in the emergency room adequately. This group of patients averaged 6 years of age and usually stayed in the hospital for 1 day. For the in-patient population, 13 (12.6%) had ADT complications with 11 re-admissions. 3.10. History of upper airway infection Some patients suffered an upper airway infection (within 3 weeks prior to surgery). They were reported recovered and were asymptomatic at the pre-operative assessment or on the day of surgery. One hundred and forty-five (32%) of the scheduled outpatients had a history of recent upper airway infection. It was noted that 8 out of 16 (50%) and 10 out of 23 (44%) of the scheduled out-patients who had
120
M.D. Schloss et al. / Int. J. Pediarr. Olorhinolaryngol. 30 (1994) I15-I22
a primary and secondary POH, respectively, had such a history. Thirty-two out of 57 (56%) of the scheduled out-patients with ADT complications had a history of upper airway infection. 3.11. Study on parental concerns Well beyond the objective capabilities needed to handle the post-operative needs of the child, parents’ attitudes, concerns and perceptions regarding the up-coming surgical procedure and their own ability to cope with the situation represented important considerations in deciding between out-patient treatment and hospitalization. Clearly, the prospect of one’s child facing surgery is anxiety-provoking in many regards, and the extent of the distress was confirmed in the questionnaire results. Nearly 15% of parents experienced a high degree of nervousness over the impending surgical procedure, with another 68% reporting somewhat lesser worry. A large majority, over SO%, believed that their child would generally co-operate well with regard to both the surgery and subsequent period of convalescence. Most revealing, however, were the parents’ feelings about their child’s first postoperative night. While 60% of the parents reported being somewhat worried if their child was hospitalized for the first night following surgery, 25% were relieved, apparently being reassured by the knowledge that in-patient care was being provided for their child. Conversely, 20% reported that having to care for their child at home would ‘terrify’ them, with an additional 58% experiencing some worry over this possibility. Only 4% of parents felt significant relief due to being able to care for the child in the home environment. It must be noted that this ‘parental concern’ study was a pilot study. This analysis was conducted prior to introducing T&A as outpatient surgery at the hospital involved. The extent of the study was to gain an impression of how parents would react to not having their children admitted overnight. There was no statistical analysis involved in this part of the study. In summary, an overwhelming majority (over 80%) of parents preferred hospitalization for their child, while the balance indicated a preference for caring for their child at home, if provided with detailed written instructions. 4. Discussion The selection criteria for ambulatory tonsillectomy and adenotonsillectomy were similar to most studies [2,8]. Over a 10 month period, 555 cases of tonsillectomy and adenotonsillectomy were performed with 452 patients (81%) initially scheduled for out-patient procedures. The comparison between in-patient and out-patient groups was presented for completeness and reference. As in most studies, the in-patient group were selected by specific selection criteria. Of the 452 scheduled out-patient procedures 91 (20%) suffered at least one complication requiring medical attention. Seventy-four (16.2%) of scheduled outpatients required hospitalization as unplanned admissions on the day of surgery or were admitted at a later date when complications occurred. Seventeen (3.8%) of scheduled outpatients with minor complications required emergency room facilities only. These
M.D. Schloss et al. /Int. J. Pedialr. Otorhinolar,vnpl. 30 11994) 115-122
171
statistics are similar to those presented by Shott et al. [S]. According to the Federated Ambulatory Surgery Associations Special Study, the incidence of bleeding associated with tonsillectomy and adenoidectomy is no greater in the ambulatory setting than in the hospital in-patient setting [4]. All surgical procedures were performed using the knife or electro-cautery dissection techniques. Numerous reviews have shown that the electro-cautery technique is associated with less intra-operative blood loss [6]. The data in this study confirms this finding, in that approximately 2.5 times more blood loss is expected with the knife dissection technique. It was also noted that all 3 patients (less than 1%) who suffered intra-operative hemorrhage underwent knife dissection technique. Primary POH is thought to be related to surgical technique [ 11. Sixteen scheduled out-patients (3.5%) experienced a primary POH with 4 (0.9”/0) severe enough to require re-operation. From the data it appeared that knife dissection technique. increased intra-operative blood loss and a recent history (within 3 weeks) of upper airway infection were associated with POH. It was noted that increased intraoperative blood loss (greater than 100 ml) was statistically significant. This association had a confidence interval for the odds ratio of equals (1.1, 9.0) for 95”/1,confidence limits. A recent history of upper airway infection and knife dissection technique were not statistically significant. However, 30% of the patients experiencing POH had all three of these factors present. The association of this triad of: (1) recent upper airway infection; (2) tonsillectomy performed by knife dissection technique; and (3) intra-operative blood loss of 100 ml or more with primary POH is clinically and statistically significant. For 95% confidence limits, the confidence interval for the odds ratio of this association is (2.8, 27). Secondary POH is known to be unrelated to surgical technique [I]. It has been reported that necrotizing tonsillar remnants and unrecognized blood clot or infection are responsible for this complication [5]. The data in this study demonstrated that the factors of recent history of upper airway infection, knife dissection and increased intra-operative blood loss were clinically significant. However, as a triad or individually they do not have any statistically significant association. The literature has failed to emphasize or even recognize aerodigestive tract complications following tonsillectomy and adenotonsillectomy. In this study 57 scheduled out-patients (12.6%) experienced this complication with 44 (10%) severe enough to require admission. Thirty-two patients (56%) had a history of recent upper airway infection. The association of such a history with aerodigestive tract complications is both clinically and statistically significant. For 95% confidence limit, the confidence interval for the odds ratio is (1.8, 5.6). When analyzing these data, it is clear that the physician in the hospital providing care for children undergoing tonsillectomy or adenotonsillectomy must understand and address the relative social circumstances as well as the factors influencing the post-operative complication rate. The selection criteria for these procedures being performed on an out-patient basis should take into account the recent history of upper airway infection even if the patient may have clinically recovered and is asymptomatic at the pre-operative assessment day. The triad, including recent history of upper airway infection, knife dissection technique, and increased intra-
122
M.D.
Schloss et al. / Int. J. Pediatr.
Ororhinolaryngol.
30 (1994)
115-122
operative blood loss of 100 ml or more should be used to help the physician to identify those at risk for primary post-operative hemorrhage. The effect on family lifestyle as the result of a surgical procedure and post-operative care of the child can be seen and hypothesized from the data presented. The indirect cost of providing primary post-operative care at home, including parental loss of time from work, the anxiety resuiting from the operation, and concern over providing in-home postsurgical attention are revealed in the study findings. 5. References Carter, R.J. and Rodger, 3. (1988) Tonsillectomy: home after 24 hours? J. Laryngol. Otol. 99, 177-178. Chiang, T.M., Sukis, A.E. and Ross, D.I. (1968) Tonsillectomy performed on an outpatient basis. Arch. Otolaryngol. 88, 307-310. Chowdhury, K., Tewfik, T.L. and Schloss, M.D. (1988) Post-tonsillectomy and adenoidectomy hemorrhage. J. Otolaryngol. 17, 46-49. Federated Ambulatory Surgery Association (1985) FASA Special Study I. Kumar, R. (1984) Secondary haemorrhage following tonsillectomyiadenoidectomy. J. Laryngol. Otol. 98, 997-998. Martinez, S.A. and Akin, D.P. (1987) Laser tonsillectomy and adenoidectomy. Otolaryngol. Clin. North Am. 20, 371-376. Segal, C., Berger, G., Basker, M. and Marshak, G. (1983) Adenotonsillectomies on a surgical dayclinic basis. Laryngoscope 93, 120% 1208. Shot& S.R., Myer, C.M. and Cotton, R.T. (1987) Efficacy of tonsillectomy and adenoidectomy as an outpatient procedure: a preliminary report. Int. J. Pediatr. Otorhinolaryngol. 13, I57- 163.
of Pediatric Otorhinolaryngology 30 (1994) 115-122
ELSEVIER
Outpatient tonsillectomy and adenoidectomy: complications and recommendations-f M.D. Schloss*“, A.K.W. Tanb, B. Schlossb, T.L. Tewfikb “Department of Orolaryngology, McGill University, Canada bDepartment of Otolaryngology, Montreal Children’s Hospital, 2300 Tupper Street, Montreal. Que H3H IP3, Canada (Received
10 May 1993; revision
received
27 January
1994: accepted
29 January
1994)
Abstract
An example of cost-effective alternatives in medical care is the increasing use of out-patient surgery for those children requiring tonsillectomy, or tonsillectomy with adenoidectomy rather than an in-patient procedure. Two studies were carried out to answer questions about the complications, in addition to post-operative hemorrhage, and also the questions about the parental views and concerns relating to providing at-home care for their children following surgery. A triad, including recent history of upper airway infection, knife dissection technique, and increased intra-operative blood loss of 100 ml or more should be used to help identify the risk of post-operative hemorrhage. Keywords;
Tonsillectomy;
Tonsillectomy
with adenoidectomy;
Ambulatory
surgery; Electro-
cautery
1. Introduction In the face of increasing pressures to control growth in health-care expenditures as the costs of medical care continue to escalate, attention has focused on identifying cost-effective treatment alternatives in a wide range of clinical conditions. Accord* Corresponding author, tPresented at The Eastern Otological
Society
Section Meeting of The American Laryngological, Rhinological Inc., Grand Hyatt Hotel, New York, NY, 28-30 January 1993.
0165-5876/94/$07.00 0 1994 Elsevier SSDI 0165-5876(94)01029-W
Science
Ireland
Ltd. All rights reserved
and
116
M.D. Schloss et al. /Int.
J. Pediatr.
Olorhinolaryngol.
30 (1994)
115-122
ingly, Canadian medical professionals are increasingly being obliged to seek out less costly treatment approaches, to meet the limited resources available to provincial authorities responsible for overseeing local health-care funding programs. In many instances, studies have confirmed that the overall quality of patient care is not diminished by the substitution of therapeutic options demonstrated to represent cost-effective alternatives to more traditional approaches. One such example is the increasing ux of out-patient surgery for those children requiring tonsillectomy, or tonsillectomy with adenoidectomy (T&A), rather than an in-patient procedure. Most prospective evaluations of out-patient tonsillectomy and T&As that have analyzed post-surgical complications requiring hospital admission, most specifically bleeding, have concluded that such complications in patients whose surgery has been performed on an ambulatory basis are no more frequent than those hospitalized following surgery [3,7]. Thus, it has been accepted that adenotonsillectomy is both safe and cost-effective when done on an out-patient basis. Most studies have analyzed post-surgical bleeding to be the major complication requiring hospitalization. However, a review of the literature reveals little discussion or consideration of other complications that require medical attention or even re-admission. Little discussion or consideration has taken place in the literature on the issues confronting the surgeon and primary-care practitioner namely, the parents, and the impact on them and other family members of providing the necessary care for their child immediately post-operatively following these common surgical procedures. In view of the complications requiring post-surgical admission to the hospital and the emotional and financial burdens inevitably placed on the families of these patients, particularly over the first post-operative day, two studies were undertaken. The first study involved a retrospective review of all tonsillectomy and adenotonsillectomy patients over a lo-month period. This study intended to answer the following questions: (1) what are the complications in addition to post-operative hemorrhage; (2) are there any factors associated with these complications that can predict which patient should be admitted to the hospital; (3) what are future recommendations with regard to out-patient surgery for tonsillectomy or adenotonsillectomy? The second study was to investigate and evaluate parental views and concerns relating to providing at-home care for their children following tonsillectomy or adenotonsillectomy. 2. Materials and methods In the first study on complications, a retrospective chart analysis of 555 cases of tonsillectomy and adenotonsillectomy between June 1990 and March 1991 was carried out. The indications for tonsillectomy and adenotonsillectomy were hypertrophic-obstructive tonsils and adenoids interfering with breathing and/or swallowing or recurring episodes of acute tonsillitis and adenotonsillitis. Patient information was recorded and tabulated into a data management software program for ,analysis. The study comprised a review of each chart including the patient’s age, sex, detailed history, including pre-operative assessment, examination and type of operation, the technique (cautery or knife dissection), intra-operative blood loss, length of hospitalization (if admission required), complications and management.
M.D. Schloss et al. /Int. J. Pediatr. Otorhinolaryngol. 30 11994) 115-122
117
In the second study on parental concerns, a total of 49 patients and their families were involved. To evaluate the impact on parents and other family members of providing immediate post-operative care for the child a questionnaire was formulated which was presented to a random sample of parents whose children were scheduled for surgery between May 1988 and September 1988. During this period all patients were routinely hospitalized for the first post-operative night. Each participant completed the same questionnaire at the pre-operative visit, then immediately predischarge the morning following surgery and finally at the first physician postoperative visit. The selection criteria established in 1989 for ambulatory tonsillectomy and adenotonsillectomy included the following: (1) over the age of 3 years; (2) living within one hour’s travel from the hospital; (3) a negative history of obstructive sleep apnea or co-existing medical problems. Post-operatively, the patients were sent home if they met the following criteria: (1) 4 h spent in the recovery room; (2) no active bleeding; (3) no vomiting; (4) good oral intake; (5) alert mental status; (6) no evidence of hypoxia on Po2 monitoring. 3. Results 3.1. Study on post-operative complications The organization of the patients according to the scheduled type of procedure (in-patient vs. out-patient) is shown in Fig. 1. Of the 555 cases of tonsillectomy and adenotonsillectomy, 103 (19%) were scheduled for in-patient procedures. The remaining 452 cases (81%) were scheduled for ambulatory procedures. Of all the patients who underwent ambulatory surgery, 91 (20%) had at least one complication while the remaining 361 (80%) had an uneventful recovery without complication (Fig. 2). Within the group of patients who had complications, 17 (19%) required emergency room management only, the other 74 patients (SlO/) with complications
Fig. 1. Outpatient
tonsillectomy
and adenoidectomy:
organization
of patients.
118
M.D.
Schloss et al. /Int.
J. Pediatr.
Otorhinolaryngol.
30 (1994)
115-122
Fig. 2. Outpatient tonsillectomy and adenoidectomy: complication rate.
were either admitted on the day of surgery as unplanned admissions, or admitted later when complications occurred. 3.2. Technique of tonsillectomy When comparing the surgical techniques used, 282 scheduled out-patients (62%) were operated by the traditional knife dissection technique, while 170 patients (38%) received electro-cautery dissection. For the in-patients, 58 (56%) underwent knife dissection. 3.3. Intra-operative blood loss For the scheduled out-patients, those that underwent knife dissection averaged 68 ml blood loss. The patients who underwent electro-cautery dissection averaged 26 ml blood loss. The data for the in-patient group was similar with knife dissection averaging 57 ml and the electro-cautery dissection technique averaging 20 ml. 3.4. Complications The complications encountered during and most commonly following tonsillectomy and adenotonsillectomy are shown in Table 1. Table 1 Outpatient tonsillectomy and adenoidectomy Complications Intra-operative hemorrhage Post-operative hemorrhage Aerodigestive tract (ADT) complications
M.D.
Schfoss et al. / Int.
J. Pediatr.
Otorhinolaryngol.
30 (1994)
115-122
119
3.5. Intra-operative hemorrhage
Intra-operative hemorrhage is defined as intra-operative blood loss of more than 5% body weight of the patient. Less than 1% (3) of all scheduled out-patients had this complication. The three patients underwent knife dissection technique for tonsillectomy and the average blood loss was 225 ml (4 x the average). All three patients were admitted post-operatively. No scheduled in-patient had an intra-operative hemorrhage. 3.6. Post-operative hemorrhage (POH) Primary post-operative hemorrhage is generally defined as hemorrhage from the operative site occurring within 24 h of surgery. Secondary hemorrhage occurs after the initial 24 h period. 3.7. Primary POH Of the scheduled out-patient population (452) 16 patients (3.5%) had a primary POH; however, only 4 (0.9%) required re-operation for control of hemorrhage. All were admitted post-operatively for observation, rehydration and antibiotics. For the scheduled in-patient group (103), two (1.9%) suffered primary POH with one patient requiring re-operation. 3.8. Secondary POH Twenty-three (5.1%) of the scheduled out-patients were complicated with secondary POH. Of these 23 patients, 19 (4.2%) were re-admitted with 4 of them requiring re-operation for hemostasis. The other 4 patients with secondary POH required emergency room management (rehydration with or without intravenous route observation and oral antibiotics) only. For those admitted, all received intravenous rehydration and antibiotics. For the scheduled in-patient population, two (1.9%) suffered secondary POH. None required management in the operating room. 3.9. Aerodigestive tract complications (ADT) This group of complications includes nausea, vomiting, dysphagia and any respiratory problem requiring medical attention. Forty-four of the scheduled out-patients (10%) required admission. Most of them were admitted immediately post-operatively as unplanned admissions or on the first post-operative day. Thirteen patients (3%) were treated in the emergency room adequately. This group of patients averaged 6 years of age and usually stayed in the hospital for 1 day. For the in-patient population, 13 (12.6%) had ADT complications with 11 re-admissions. 3.10. History of upper airway infection Some patients suffered an upper airway infection (within 3 weeks prior to surgery). They were reported recovered and were asymptomatic at the pre-operative assessment or on the day of surgery. One hundred and forty-five (32%) of the scheduled outpatients had a history of recent upper airway infection. It was noted that 8 out of 16 (50%) and 10 out of 23 (44%) of the scheduled out-patients who had
120
M.D. Schloss et al. / Int. J. Pediarr. Olorhinolaryngol. 30 (1994) I15-I22
a primary and secondary POH, respectively, had such a history. Thirty-two out of 57 (56%) of the scheduled out-patients with ADT complications had a history of upper airway infection. 3.11. Study on parental concerns Well beyond the objective capabilities needed to handle the post-operative needs of the child, parents’ attitudes, concerns and perceptions regarding the up-coming surgical procedure and their own ability to cope with the situation represented important considerations in deciding between out-patient treatment and hospitalization. Clearly, the prospect of one’s child facing surgery is anxiety-provoking in many regards, and the extent of the distress was confirmed in the questionnaire results. Nearly 15% of parents experienced a high degree of nervousness over the impending surgical procedure, with another 68% reporting somewhat lesser worry. A large majority, over SO%, believed that their child would generally co-operate well with regard to both the surgery and subsequent period of convalescence. Most revealing, however, were the parents’ feelings about their child’s first postoperative night. While 60% of the parents reported being somewhat worried if their child was hospitalized for the first night following surgery, 25% were relieved, apparently being reassured by the knowledge that in-patient care was being provided for their child. Conversely, 20% reported that having to care for their child at home would ‘terrify’ them, with an additional 58% experiencing some worry over this possibility. Only 4% of parents felt significant relief due to being able to care for the child in the home environment. It must be noted that this ‘parental concern’ study was a pilot study. This analysis was conducted prior to introducing T&A as outpatient surgery at the hospital involved. The extent of the study was to gain an impression of how parents would react to not having their children admitted overnight. There was no statistical analysis involved in this part of the study. In summary, an overwhelming majority (over 80%) of parents preferred hospitalization for their child, while the balance indicated a preference for caring for their child at home, if provided with detailed written instructions. 4. Discussion The selection criteria for ambulatory tonsillectomy and adenotonsillectomy were similar to most studies [2,8]. Over a 10 month period, 555 cases of tonsillectomy and adenotonsillectomy were performed with 452 patients (81%) initially scheduled for out-patient procedures. The comparison between in-patient and out-patient groups was presented for completeness and reference. As in most studies, the in-patient group were selected by specific selection criteria. Of the 452 scheduled out-patient procedures 91 (20%) suffered at least one complication requiring medical attention. Seventy-four (16.2%) of scheduled outpatients required hospitalization as unplanned admissions on the day of surgery or were admitted at a later date when complications occurred. Seventeen (3.8%) of scheduled outpatients with minor complications required emergency room facilities only. These
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statistics are similar to those presented by Shott et al. [S]. According to the Federated Ambulatory Surgery Associations Special Study, the incidence of bleeding associated with tonsillectomy and adenoidectomy is no greater in the ambulatory setting than in the hospital in-patient setting [4]. All surgical procedures were performed using the knife or electro-cautery dissection techniques. Numerous reviews have shown that the electro-cautery technique is associated with less intra-operative blood loss [6]. The data in this study confirms this finding, in that approximately 2.5 times more blood loss is expected with the knife dissection technique. It was also noted that all 3 patients (less than 1%) who suffered intra-operative hemorrhage underwent knife dissection technique. Primary POH is thought to be related to surgical technique [ 11. Sixteen scheduled out-patients (3.5%) experienced a primary POH with 4 (0.9”/0) severe enough to require re-operation. From the data it appeared that knife dissection technique. increased intra-operative blood loss and a recent history (within 3 weeks) of upper airway infection were associated with POH. It was noted that increased intraoperative blood loss (greater than 100 ml) was statistically significant. This association had a confidence interval for the odds ratio of equals (1.1, 9.0) for 95”/1,confidence limits. A recent history of upper airway infection and knife dissection technique were not statistically significant. However, 30% of the patients experiencing POH had all three of these factors present. The association of this triad of: (1) recent upper airway infection; (2) tonsillectomy performed by knife dissection technique; and (3) intra-operative blood loss of 100 ml or more with primary POH is clinically and statistically significant. For 95% confidence limits, the confidence interval for the odds ratio of this association is (2.8, 27). Secondary POH is known to be unrelated to surgical technique [I]. It has been reported that necrotizing tonsillar remnants and unrecognized blood clot or infection are responsible for this complication [5]. The data in this study demonstrated that the factors of recent history of upper airway infection, knife dissection and increased intra-operative blood loss were clinically significant. However, as a triad or individually they do not have any statistically significant association. The literature has failed to emphasize or even recognize aerodigestive tract complications following tonsillectomy and adenotonsillectomy. In this study 57 scheduled out-patients (12.6%) experienced this complication with 44 (10%) severe enough to require admission. Thirty-two patients (56%) had a history of recent upper airway infection. The association of such a history with aerodigestive tract complications is both clinically and statistically significant. For 95% confidence limit, the confidence interval for the odds ratio is (1.8, 5.6). When analyzing these data, it is clear that the physician in the hospital providing care for children undergoing tonsillectomy or adenotonsillectomy must understand and address the relative social circumstances as well as the factors influencing the post-operative complication rate. The selection criteria for these procedures being performed on an out-patient basis should take into account the recent history of upper airway infection even if the patient may have clinically recovered and is asymptomatic at the pre-operative assessment day. The triad, including recent history of upper airway infection, knife dissection technique, and increased intra-
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operative blood loss of 100 ml or more should be used to help the physician to identify those at risk for primary post-operative hemorrhage. The effect on family lifestyle as the result of a surgical procedure and post-operative care of the child can be seen and hypothesized from the data presented. The indirect cost of providing primary post-operative care at home, including parental loss of time from work, the anxiety resuiting from the operation, and concern over providing in-home postsurgical attention are revealed in the study findings. 5. References Carter, R.J. and Rodger, 3. (1988) Tonsillectomy: home after 24 hours? J. Laryngol. Otol. 99, 177-178. Chiang, T.M., Sukis, A.E. and Ross, D.I. (1968) Tonsillectomy performed on an outpatient basis. Arch. Otolaryngol. 88, 307-310. Chowdhury, K., Tewfik, T.L. and Schloss, M.D. (1988) Post-tonsillectomy and adenoidectomy hemorrhage. J. Otolaryngol. 17, 46-49. Federated Ambulatory Surgery Association (1985) FASA Special Study I. Kumar, R. (1984) Secondary haemorrhage following tonsillectomyiadenoidectomy. J. Laryngol. Otol. 98, 997-998. Martinez, S.A. and Akin, D.P. (1987) Laser tonsillectomy and adenoidectomy. Otolaryngol. Clin. North Am. 20, 371-376. Segal, C., Berger, G., Basker, M. and Marshak, G. (1983) Adenotonsillectomies on a surgical dayclinic basis. Laryngoscope 93, 120% 1208. Shot& S.R., Myer, C.M. and Cotton, R.T. (1987) Efficacy of tonsillectomy and adenoidectomy as an outpatient procedure: a preliminary report. Int. J. Pediatr. Otorhinolaryngol. 13, I57- 163.