Jane Montgomery & Shyam Singham

(Original article published 2013, updated 2020)

Patient Selection

• Age 3 and over
• Caution in patients with severe sleep apnoea
• Within 30 mins drive of hospital
• Transport in own car

Anaesthetic Techniques

• EMLA or Ametop cream
• Propofol 4mg/kg
• Disposable reinforced LMA (a size down from what you would otherwise use) size 2 if <20kg
• Maintenance with isoflurane or sevoflurane in air and oxygen
• Spontaneous respiration
• Dexamethasone 0.25mg/kg
• Ondansetron 0.1mg/kg
• Crystalloids 10ml/kg
• In recovery free fluids and food on demand

Surgical Technique

• Coblation surgical technique to reduce PONV with decreased per-operative bleeding
• 5% lignocaine with phenylephrine spray to tonsillar beds at the end of surgery

Peri-operative Analgesia

• Preoperative ibuprofen 5mg/kg
• Preoperative paracetamol 15-20 mg/kg
•  IV Fentanyl 1-2mcg/kg intraoperatively

Take Home Medication

• Azithromycin 10mg/kg for 3 days od
• Ibuprofen 5-10mg/kg for 1 week qds
• Paracetamol 15mg/kg qds for 1 week qds

Organisational Issues

• Nursing observations for 6hrs postoperatively
• Nurse led discharge 6hrs postoperatively so need to be on morning list
• Surgeon needs to be contactable in the afternoon if there are any concerns

Common Pitfalls

• Site rLMA in anaesthetic room and do not tape to mouth. Check airway patent with head in extension to mimic surgical position
• Ensure surgeon uses relatively large Doughty blade to avoid compression of rLMA on posterior third of tongue base
• When gag is put in, if the surgeon can see rLMA cuff it’s not far enough in
• Insertion of gag initially can induce apnoea momentarily—check airway patent with brief bagging
• If still a problem release gag and put a little tension on the rLMA as it is replaced (may
  stop rLMA folding on itself). Sometimes the obstruction is relieved when the surgeon places the Draffin rods
• If still a problem revert to RAE endotracheal tube

Anticipated Day Case Rates

• 95%