title: Future of pediatric tonsillectomy and perioperative outcomes.
abstract: OBJECTIVE
  Although commonly performed, pediatric tonsillectomy is not necessarily a low risk procedure due to potentially life threatening perioperative complications. There is paucity of literature on lethal anesthesia and surgical complications of tonsillectomy. In this article, we have reviewed both minor and serious complications following tonsillectomy. Hemorrhage, burn injuries, respiratory complications, postoperative nausea and vomiting, and pain management are discussed. We have highlighted our practice of pain management at Cincinnati Children's Hospital after tonsillectomy recent warning about codeine by the FDA on children undergoing tonsillectomy. We describe post-tonsillectomy outcomes including postanesthesia care unit stay, post discharge maladaptive behavioral outcomes and finally effective ways to identify children at risk for anesthesia and a few preventive strategies.
  
  
  METHODS
  In addition to literature review, the LexisNexis "MEGA™ Jury Verdicts and Settlements" database was reviewed from 1984 through 2010 for deaths and complications during and following tonsillectomy. Data including year of case, cause of death, surgical, anesthetic and postoperative opioid related complications, injury, case result, and judgment awarded were collected and analyzed.
  
  
  RESULTS
  The results of this analysis are presented with an emphasis on hemorrhage and on anesthesia and opioid related claims and their characteristics. Two hundred and thirty-three claim reports were reviewed. There were 96 deaths (41%) and 137 perioperative injuries (59%). Deaths were primarily related to surgery (n=46, 48%) with post-tonsillectomy bleed the most frequent cause (n=38, 40%) followed by opioid toxicity (n=17, 18%) and anesthesia complications (n=9, 9%). Non-fatal injuries included, postoperative bleeding (n=59, 25%), impaired function (n=29, 12%), anoxic events (n=20, 9%) and postoperative opioid toxicity (n=20, 8.6%). Anoxic event was noted to have the highest monetary award with a mean award at $9,017,379. Injuries (including anoxia) had higher mean monetary awards than deaths.
  
  
  CONCLUSIONS
  Tonsillectomy in children carries a high risk of perioperative complications and malpractice claims. Though postoperative bleeding is the most common complication associated with malpractice claims, anoxia related to anesthesia and opioids had the greatest overall risk from a monetary standpoint.
authors.affiliation: Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
authors.forename: Rajeev
authors.initials: R
authors.lastname: Subramanyam
authors.forename: Anna
authors.initials: A
authors.lastname: Varughese
authors.forename: J Paul
authors.initials: JP
authors.lastname: Willging
authors.forename: Senthilkumar
authors.initials: S
authors.lastname: Sadhasivam
mesh_terms: D000293:Adolescent; D000701:Analgesics, Opioid / Q000009:adverse effects* / Q000627:therapeutic use; D000758:Anesthesia / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D003061:Codeine / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D007223:Infant; D009293:Opioid-Related Disorders / Q000453:epidemiology* / Q000209:etiology; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D019106:Postoperative Hemorrhage / Q000453:epidemiology* / Q000209:etiology; D012307:Risk Factors; D014068:Tonsillectomy / Q000009:adverse effects*; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D003061:Codeine