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\begin{document}

\title{Enhanced Recovery After Tonsillectomy}



\author[1]{Marc Logarta}%
\author[2]{Anne McCready}%
\author[3]{Alan Cheng}%
\author[4]{Alexander Duller}%
\affil[1]{Strathfield Private Hospital}%
\affil[2]{Health Policy Analysis Pty Ltd}%
\affil[3]{Children's Hospital at Westmead}%
\affil[4]{Westmead Hospital}%


\vspace{-1em}



  
  \date{May 23, 2024}


\begingroup
\let\center\flushleft
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\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objectives Investigation of whether the duration of fasting
preoperatively has an impact on pain and return to normal function after
tonsillectomy To investigate the impact of the duration of preoperative
fasting on pain and return to normal function after tonsillectomy.
Design Retrospective study with surgeon blinded to the participants
undergoing tonsillectomy with or without adenoidectomy Setting
University teaching hospital, Sydney, Australia Participants A total of
174 children (n=174) ages 4-12 years old between February 2017 to April
2020 were enrolled. The children were randomised to receive instructions
either from the staff at the hospital (n=90) or by the anaesthetist
(n=84) in terms of exact pre-operative fasting. Main Outcome measures
Fasting times, clear liquid caloric intake 2 hours prior to surgery and
Parents Postoperative Pain Measures (PPPM) were documented and analysed.
Secondary measures of analgesia usage, number of postoperative nausea or
vomiting events were also analysed. Results Observed difference were
noted between the instructed fasting period and the actual fasting
period. Significant difference in PPPM scores was noted between the
Hospital group and the juice group (p\textless{}0.001). No significant
difference was noted at first to 3rd day (p=0.11) or by the 8th to 10th
postoperative day (p=0.93). There was no difference in oxycodone usage
between the two groups (p=0.52), or in postoperative nausea and vomiting
(p=0.43) Conclusions Significantly lower PPPM scores were noted on day
of surgery in the group that had fasting minimised. The effects appeared
to trend in a positive manner but larger number of cases need to be
performed for results to be of greater significance. Further research is
required into the impact of caloric nutrition to enhance recovery after
tonsillectomy.%
\end{abstract}%



\sloppy


\textbf{Enhanced Recovery After Tonsillectomy}

\textbf{Summary:} Approximately 100 million tonsillectomies have been
performed worldwide in the century since the procedure was popularised.
In Australia, tonsillectomy is one of the most common surgical
procedures, with over 16,500 operations occurring at public hospitals
annually. In the United States, about 186,000 procedures are performed
on an outpatient basis every year(1). In spite of the fact that
tonsillectomy remains a very common surgical procedure, there is little
evidence to support traditional perioperative practices. Currently, some
patients are given fasting instructions by the hospital/nursing staff
and some patients are given fasting instructions by the anaesthetists
per standard international guidelines.

This study is the first of its kind that investigates perioperative
fasting for patients undergoing tonsillectomy with or without
adenoidectomy.

\emph{Abstract:}

Objectives: To determine if varying fasting times play a role in
post-tonsillectomy paediatric patient outcomes

Design: Quasi-experimental, prospective, surgeon-blinded, single-centre
study

Settings: \textless{}blinded for review\textgreater{} in Sydney,
Australia

Participants: Children 4---12 years old(n=180), admitted for
tonsillectomy or adenotonsillectomy. Randomised into Hospital Group(HG)
and Anaesthetic Group(AG).

Main outcome measures: The primary measure is the difference in patient
pain and return to normal function as measured by the Parents'
Postoperative Pain Measure(PPPM). The secondary measures are differences
in adverse complications such as postoperative analgesia requirements,
nausea and vomiting.

Results: AG had significantly reduced Day 0 PPPM score compared to HG.
No significant difference in medium term (Day 1-8) PPPM scores or
secondary outcomes.

Conclusions: Shorter fasting times correlate with improved Day 0
post-operative pain scores.

Keywords: fasting, tonsils, perioperative, pain, adenoids, anaesthesia,
evidence based medicine, outcomes

\emph{Key Learning Points:}

\begin{enumerate}
\tightlist
\item
  Shorter fasting times significantly improved PPPM scores on
  post-operative day 1.
\item
  Even in the shorter fasting time group, patients' fasting times were
  on average 1.5 hours longer than instructed.
\item
  There were lower pain scores in the shorter fasting time group on
  post-operative days 1-3, however this was not statistically
  significant.
\item
  There were slightly higher rates of post-operative nausea/vomiting in
  the shorter fasting time group, however not statistically significant.
\item
  There was less use of oxycodone post-operatively in the shorter
  fasting time group, although not statistically significant.
\end{enumerate}

\textbf{1. Introduction:} In the mid-1990's a gap in understanding
prompted a group of surgeons, led by Dr Henrik Kehlet from Copenhagen,
to devise and implement early recovery efforts for certain surgeries.
Building upon Dr Kehlet's work, a multinational group of surgeons and
anaesthetists started the Enhanced Recovery After Surgery(ERAS) research
group. Interest in perioperative protocols has become increasingly used
for colorectal surgery and gynaecologic surgery(2).

In the past two decades, protocols have been developed that have been
found to reduce hospital length of stay, decrease infections and lower
readmission rates(3). These protocols have been developed most notably
for colorectal surgery and have taken hold across the United Kingdom,
the United States and the European continent.

Tonsillectomy is a common operation associated with a high incidence of
postoperative pain and significant postoperative nausea and vomiting. We
seek to investigate a whether the length of fasting is associated with
pain and return to normal function after tonsillectomy.

\textbf{2. Materials and Methods:}

\textbf{2.1. Patients}

A quasi-experimental study was designed with the approval of the joint
Ethical Committee of \textless{}blinded for review\textgreater{} and the
Medical Advisory Committee of \textless{}blinded for
review\textgreater{}.

We administered PPPM questionnaires to parents of patients that
investigated pain ratings, behaviour and medication use. PPPM was
utilised as it is a validated tool for assessment of pain by parents
following their child's surgery(4). The data was collected between
February 2017-April 2020. Children 4---12 years old(n=180), admitted for
tonsillectomy or adenotonsillectomy were invited to participate in the
study. Children with diabetes, gastrooesophageal problems, involvement
in another study, sensitivity to any trial drug, morbid obesity,
cognitive impairment or other severe disease were excluded. Informed
consent was obtained in writing from the parents and verbally from the
children where possible.

\textbf{2.2. Grouping}

Prior to each full operating day, half of the patients were randomly
assigned to receive fasting instructions from the hospital and the other
half received fasting instructions from the anaesthetist.

\textbf{Hospital Group(HG)} had fasting guidelines as normally
recommended by the hospital nursing staff. These patients were told to
fast for 6 hours(solids) and 2 hours(water) prior to surgery.

\textbf{Anaesthetic Group(AG)} had fasting guidelines as recommended in
preoperative anaesthetic telephone consultation. This involved similar
fasting guidelines(fast for 6 hours prior to surgery for solids and 2
hours for clear liquids) with additional instruction to consume 2 mL/kg
of clear apple juice 2 hours prior to their scheduled surgical time.

The sample size(180) was determined with power analysis with the t-test
at a power of 80\%(at 5\% significance level) to detect a significant
difference between a mean PPPM value of 10 in the Hospital Group and a
mean PPPM value of 8 in Anaesthetic Group, assuming a standard deviation
of 4. The above sample size estimation has incorporated a drop out rate
of 15\%.

\textbf{2.3. Surgery and perioperative setting}

There was a single specialist surgeon and specialist anaesthetist for
both groups and the surgical technique did not differ between the study
groups. The surgeon was blinded to the fasting status of the patients.

No sedative premedication was administered, and the patients underwent
inhalational induction with sevoflurane. Fentanyl 1mg/kg was used for
anaesthesia induction, and the patients were not paralyzed for
endotracheal intubation. In addition, the patients received
Dexamethasone 0.1 mg/kg, Paracetamol 12.5mg/kg, Clonidine 1mcg/kg and
intravenous antibiotics. The fluid deficit was calculated using the
Holliday--Segar formula(100ml/kg/day for the first 10kg of weight,
50ml/kg/day for the next 10kg and 20ml/kg/day for the weight over 20kg).
Intravenous fluid(Lactated Ringers) was given as a bolus
intraoperatively to correct for the calculated fluid deficit.

Anaesthesia was maintained with 1---2 MAC of sevoflurane in air,
depending on the required level of anaesthesia.

During the surgery, preemptive analgesia-administration of local
anaesthetic was given prior to excision of tonsils. Bupivicaine with
epinephrine 0.25\% or Ropivacaine 1\% was administered to the lesser
palatine nerves at the junction of the hard and soft palate. During the
operation, the specialist surgeon focused on minimal tissue damage to
key areas -- anterior and posterior tonsillar pillars, the uvula, the
underlying constrictor muscles, the posterior oropharyngeal mucosa, the
buccal and labial tissues and the tongue.

The adenoids were removed under direct vision with a nasally introduced
zero-degree telescope, using an appropriate sized Barnhill adenoid
curette technique, along with or without the suction diathermy at
settings of Cutting Blend 30 and Coagulation Spray 30. Complete
haemostasis was achieved with temporary nasopharyngeal gauze swabs
and/or the use of diathermy with these settings.

To remove the palatine tonsils, the diathermy device generally used the
following parameters ``cutting blend'' setting of 10; ``coagulation
spray'' setting of 7; and bipolar coagulation standard setting of 6. To
avoid injury to remaining tonsillar area tissues, the surgeon aimed to
perform firm tonsil tissue retraction to allow precise dissection of the
palatine tonsils from the underlying mucosal surfaces of the anterior
and posterior pillars which carry the neuronal fibres of the lesser
palatine nerve and the branches of the glossopharyngeal nerve fibres
respectively.

Prophylactic control of bleeding points were performed at the tonsillar
branch of the facial artery, the tonsillar branches of the ascending
pharyngeal artery, the dorsal branch of the lingual artery and the
descending palatine artery.

The surgeon minimised additional soft tissue trauma by taking care to
minimise blunt dissection of the underlying constrictor muscles,
circumvent the use of catheters for retraction of the soft palate and
avoided finger palpation of the adenoid bed. The surgeon utilised
telescopic identification through the nose to ensure good adenoidal
clearance without causing velopharyngeal incompetence or leaving
substantial residual adenoid tissue at the posterior nasal choana. The
operated area would then be checked to ensure no significant residual
clots or retained swabs, and the surgical count with the scrub nurse
would be performed.

At the end of surgery, the child was extubated when spontaneous
respiration was regular and adequate. After extubation, the child was
transferred to the postanaesthesia care unit(PACU) for continuous
monitoring of vital signs and assessment of pain, as well as nausea and
vomiting. No patients had postoperative intravenous fluids routinely
given, but were encouraged to return to normal oral intake of fluids and
food. The patients were transferred to the ward when they were fully
awake and their cardiovascular and respiratory status was stable.

\textbf{2.4 Outcomes}

The primary outcome variable is the PPPM score. The PPPM score is
determined with a 15-item questionnaire with each item corresponding to
a 1 if positive. Scores may range from 0-15; lower scores are associated
with less pain and a closer approximation to normal activities.

Secondary outcomes include oxycodone usage(mg/kg in the first 24 hours)
and number of episodes of nausea/vomiting. Oxycodone usage was recorded
on the medication record by the nurse that administered it. Nausea was
recorded if the child was able to express it. Vomiting was the forcible
ejection of gastric contents through the mouth. This was reported by the
parents as part of the interview on postoperative day 0(POD 0), days
1-3(POD 1-3)and days 8-10(POD 8-10)(Appendix1).

\textbf{2.5 Data collection}

The parents were asked to complete the PPPM Parent
questionnaire(Appendix 1) on postoperative day 0, days 1-3 and days 8-10
based on parent availability. On the day of surgery(POD 0) the PPPM was
completed by the anaesthetist on the paediatric ward or via telephone
call if the patient had been discharged. The following PPPM on POD 1-3
and POD 8-10 was done via a telephone call by an anaesthetist. Oxycodone
usage(mg/kg) were recorded over the 24 hours immediately following
surgery as well as number of episodes of nausea or vomiting. This was
recorded by the nursing staff as part of the medication record and
nursing notes

\textbf{3 Results}

Data from 174 patients was registered on postoperative day(POD) zero,
POD 1-3 and POD 8-10 via PPPM questionnaire given to the parents.
Patient characteristics are shown in Table 1 and a summary of survey
results are shown in Table 3. Six families were lost to follow-up and
were not contactable after they were discharged from hospital. The
children that were given fasting instructions by the hospital(HG) did
not differ significantly from the children that were given fasting
instructions by the anaesthetist. The patients did not have
statistically significant differences in gender distribution. They were
also similar in age and weight(see Table 1).

\textbf{3.1. Fasting}

Children's preoperative fasting time for liquids differed significantly
between groups(see Table 2). The children in the Anaesthetic Group(AG)
were told to consume 2mL/kg of clear apple juice 2 hours prior to their
scheduled surgical start time. Even with these instructions, the average
time from apple juice to surgical start time was 3.5 hours.

Even with clear instructions given to both groups, the patients remained
fasting for much longer than instructed. The hospital group had the
longest time in between when they had their last fluid intake and when
surgery actually started.

\textbf{3.2 PPPM scores}

The mean PPPM scores are shown in Figure 1. On the first postoperative
day, the parents of the children in the hospital group reported
significantly higher PPPM scores than the juice
group(p\textless{}0.001).

The parents of the patients were contacted again at home(POD 1-3) to
provide a response for the PPPM. The group that had been minimally
fasted still had a slightly lower PPPM score but this was not
statistically significant(p=0.115). No significant difference was seen
on POD 8-10. All surgeries were associated with functional limitations
on the evening following surgery(POD 0), which persisted for the first
week.

\textbf{Discussion}

Previous studies have shown that paediatric patients who have undergone
adenotonsillectomy/tonsillectomy can experience significant functional
limitation and pain(5). Few studies have focused on the interaction
between perioperative factors and functional limitations that occur
post-tonsillectomy. Perioperative factors such as prolonged periods of
fasting for all patients and especially children may result in
dehydration and discomfort(6). In fact, many studies have shown that
minimising fasting may enhance recovery in multiple types of
surgeries(7,8). Shorter fasting guidelines have been advocated by the
European, Canadian and American anaesthetic societies(9,10,11). With
current fasting guidelines, there has been no increase in the incidence
of aspiration(12).

The children in both groups of our study were similar in gender, age and
weight. Fasting was prolonged in both groups, but fasting times for
clear liquids were reduced in the group that had been given anaesthetic
instructions by the anaesthetic team by almost 10 hours. The fasting
times were unexpectedly prolonged in both groups. A major impetus for
this project, was the need to quantify the duration of fasting.

The PPPM has been used as a measure of pain in paediatric populations
and previous research has identified that a PPPM of \textgreater{}6
correlated with significant pain(13). Lower PPPM scores on the day of
surgery were associated with the group that had fasting minimised. The
difference was not seen in the following days after surgery and PPPM
scores were similar in both groups. Causation cannot be established, but
the results suggest that further investigation may be warranted. Other
literature suggests that a possible mechanism may be the blunting of the
catabolic response to surgical trauma may make patients less vulnerable
to postoperative complications(15). Enhanced recovery after surgery
protocols have emphasised the consumption of carbohydrate drinks 2 hours
before surgery to retain anabolic homeostasis(16). These protocols are
currently used in major head and neck surgery, colorectal surgery,
breast reconstruction, total joint replacement and cardiac
surgery(17,18,19). Carbohydrate loading has been shown to reduce insulin
resistance in orthopaedic surgery(20,21). In total hip replacement some
small studies have been shown to show positive effects on pain and
nausea(22).

There were several limitations to this study. Firstly, the patient,
parent/caregiver and the anaesthetist were not blinded to the
administration of juice. Like any other non-blinded study, this trial
also suffers from the same concerns of investigator(anaesthetist) bias.
Complete blinding of the patient and anaesthetist would have been
impossible due to the nature of the intervention and safety of the
anaesthetic induction including appropriate pre-operative history taking
by the anaesthetist.

The consultant anaesthetist performed the PPPM interview. This may have
created a reporting bias. However, this was minimised by ensuring that
all PPPM interviews abided to the specific questionnaire provided.

In addition, the PPPM is a 3rd party assessment of a subjective
experience, and self-report is the ideal measure of post-operative pain.
However, since parents and caregivers are the advocates for the patients
in hospital and they control administration of pain medication to their
children at home, it remains especially important that they accurately
assess their children's pain. Other limitations include the fact that
our study was limited to tonsillectomies(+/-adenoidectomy)without
prolonged hospitalisations. The findings may not translate to other
types or surgeries and patient populations.

Knowledge translation of current evidence is needed to reduce fasting
times in children undergoing surgical procedures. The effort to minimise
unnecessary preoperative fasting in paediatric anaesthesia is in
evolution. This project showed that there may be improved return to
normal activity for patients following tonsillectomy with closer
adherence to international guidelines of fasting. Study results revealed
inconsistencies between practice and guideline recommendations, as well
as opportunities for improvement to minimise fasting in paediatric
patients prior to surgery.

\textbf{Data availability statement:} The data that support the findings
of this study are available from the corresponding author upon
reasonable request.

\textbf{Appendix 1}

Parent Questionnaire(PPPM)

Does your child\ldots{}

1. Whine or complain more than usual?

2. Cry more easily than usual?

3. Play less than usual?

4. Not do the things s/he normally does?

5. Act more worried than usual?

6. Act more quiet than usual?

7. Have less energy than usual?

8. Refuse to eat?

9. Eat less than usual?

10. Hold the sore part of his/her body?

11. Try not to bump the sore part of his/her body?

12. Groan or moan more than usual?

13. Look more flushed than usual?

14. Want to be close to you more than usual?

15. Take medication when s/he normally refuses?

How much does your child weigh?

How long did your child fast before surgery?

Does your child have any preexisting medical conditions?

How many doses of paracetamol and/or endone has your child needed in the
past 24 hours?

How many times has your child vomited in the past 24 hours?

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