On the decision of outpatient adenoidectomy and adenotonsillectomy in children

[Hypertrophy of adenoid vegetation in modern treatment conditions]

We present data on the hypertrophy of adenoid vegetation in modern treatment conditions. Actual aspects of the etiology of hypertrophy of adenoid vegetation and chronic adenoiditis are discussed, and mechanisms of the formation of local immunity and the effect of immunomodulating therapy are also described. Data on the morphology of adenoids, immunity condition after exposure to modern drugs and the rationality of treatment in frequently ill children are presented.

Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.

Safety of outpatient tonsillectomy in children: a review of 6 years in a tertiary hospital experience

OBJECTIVE

We present our experience with outpatient tonsillectomy in children and critically review safety to support the outpatient policy.

STUDY DESIGN AND SETTING

We conducted a retrospective chart review from January 1995 through December 2000 in the pediatric otolaryngology unit of a tertiary care university hospital.

RESULTS

One thousand two hundred forty-three patients were accepted in the outpatient program with permissive criteria. Postoperative observation time ranged from 3 to 5 hours (median, 4.5 hours). The overall rate of complications was 9.3% (n = 116). Primary and secondary bleeding rates were 6.27% (n = 78) and 0.48% (n = 6), respectively. Thirty-six children (2.9%) had major bleeding; 2 of them were not identified in day-hospital (0.16%). Discharge was delayed in 103 patients (8.3%), and 13 patients showed complications after discharge (about 1% readmission rate).

CONCLUSION

Our program outcomes support safety. Outpatient surgery is meant to provide comfort to the patient and efficiency to the health care system, without impairing safety; in our experience, most tonsillectomies in children comply with these objectives.

SIGNIFICANCE

Outpatient tonsillectomy in children may be safe even with permissive criteria, when an appropriate setting is available.

Day stay pediatric tonsillectomy--a safe procedure

OBJECTIVE

There is a controversy about day stay pediatric tonsillectomy in the UK and Australia. New Zealand has a similar health structure and we wished to compare day stay tonsillectomy from our hospital with those reported from other centers.

METHODS

We performed a prospective audit of day stay tonsillectomy to determine conversion to hospital admission rate and the incidence of postoperative hemorrhage.

RESULTS

There were 4850 paediatric tonsillectomies performed with 80% of them as day stay procedures over a 9-year study period (1993-2002) in a university-affiliated tertiary children's hospital. The primary postoperative hemorrhage rate (within 24h of surgery) was 0.9% (CI 0.68-1.22%) and 83% occurred within the mandatory 4h postoperative observation period. Primary hemorrhage requiring re-operation to achieve hemostasis occurred in 18 children (0.37%, CI 0.2-0.54%). No child with a primary hemorrhage who presented after discharge following day stay surgery required re-operation or blood transfusion. Day stay surgery was planned in 4041 children and 4.7% (CI 4.1-5.4%) required conversion to hospital admission. Postoperative vomiting was the most common indication for conversion (2.65%, CI 2.2-3.1%), while hemorrhage contributed only 0.95% (CI 0.64-1.24%).

CONCLUSIONS

This study was performed in a health system similar to that of Australia and the UK. Complication and conversion rates are similar to those reported in North American centers. Pediatric day stay tonsillectomy is a safe procedure when performed with strict preoperative criteria, trained day stay unit (DSU) staff, and with in-patient facilities on site.

Day-case tonsillectomy in children: parental attitudes and consultation rates

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 2-week 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 pre-operative information are prerequisites for day-case tonsillectomy.

Intravenous home hydration in pediatric patients following adenotonsillectomy

OBJECTIVE

To determine the feasibility, safety and efficacy of intravenous home hydration for pediatric postoperative adenotonsillectomy patients.

METHOD

Nonrandomized control trial of two groups of pediatric patients following adenotonsillectomy--one with (H) and one without postoperative home intravenous hydration (WH).

SETTING

A tertiary care, university-based children's hospital.

INTERVENTION

Administration of 25 cm3 kg-1 of Lactated Ringer's solution once a day for 3 days via an intravenous catheter.

RESULTS

Three of 22 patients in the (WH) group and none of the 25 patients in the (H) group required an emergency room admission for dehydration. Difficulty swallowing and activity level were found to be statistically different based on chi2-analysis (P<0.05). The hydration group (H) had a greater swallowing difficulty score (1.4) compared with the nonhydration (WH) group (0.06). The (H) group had a lower activity score (0.2) compared with the (WH) group. Other parameters such as duration of pain, the severity of pain, days until oral feeds could be taken without difficulty, degree of dysphagia, degree of neck, throat, tongue and ear pain were not statistically different between the two groups based on chi2-analysis (P<0.05). There were no complications associated with intravenous hydration.

CONCLUSION

Increased efficacy from intravenous hydration was not shown based on a number of parameters. Selected patients with a high likelihood to develop dehydration or medically intractable emesis may benefit from intravenous hydration and may avoid emergency room or hospital admission. Bolus infusions of 25 cm3 kg-1 of Lactated Ringer's solution by home care nursing can be implemented safely in pediatric patients.