Intra-operative Management
Goals of intra-operative management
Goals
Smooth induction & intubationAvoid hypertension / tachycardia during mouth-gag placement · adequate depth
PONV & analgesia controlMultimodal, opioid-sparing
Smooth extubationConstant vigilance for kinking / accidental extubation
1
OT preparation
- Airway equipment + a range of tube sizes (oral/nasal RAE tubes, plain ETTs, oral airways), emergency drugs, and suction apparatus checked and ready.
2
Induction
- Inhalational (sevoflurane) or intravenous induction, per the child and the airway.
3
Intubation
- Intubate under deep GA; use a cuffed ETT or microcuff tube (protects against soiling and allows a leak-free low-pressure seal).
- Adenotonsillectomy may use nasotracheal intubation; throat well packed after tube placement.
- A rise in airway pressure warns of ETT kinking by the gag; a fall in tidal volume / capnograph loss warns of dislodgement; HR & BP rise signal light anaesthesia at gag placement (deepen).
4
Positioning — Rose position
- Rose position (head extended, shoulder roll) for direct view of the tonsils; requires atlanto-occipital extension + cervical-spine extension.
- Protect the eyes (taped); re-check gag/tube after positioning (risk of dislodgement on extension).
5
Maintenance
- Inhaled agent + bolus opioid, keeping adequate depth to avoid the hypertension/tachycardia of surgical stimulation.
- Local anaesthetic + adrenaline infiltrated into the tonsillar capsule/bed reduces bleeding and pain — but beware: excess volume causing a bilateral glossopharyngeal (IX) nerve block → post-op respiratory obstruction.
- IV fluids — blood loss is difficult to estimate; replace judiciously.