T&A Triage with or without Preoperative Polysomnography Clinical Pathway – Inpatient and Outpatient Specialty Care

Child Undergoing Tonsillectomy and/or Adenotonsillectomy with or without Pre-Operative Polysomnography

Comorbid conditions that increase risk for complications intra/postoperatively
Consider sleep study
- Down syndrome
- Craniofacial anomalies
- Neuromuscular disease
- Chronic lung disease
- Sickle cell disease
- Metabolic disease
- BMI ≥ 95th percentile

Preoperative Evaluation

ENT Office Visit
History and Physical
Review polysomnography results if applicable
Assessment by Anesthesia Resource Center (ARC)

	Ambulatory Surgical Center (ASC)	KOPH	PHL Day Surgery	PHL
Age Comorbid Conditions	≥ 3.5 yrs Comorbid conditions cleared by Anesthesia	All ages No known difficult airway See selection criteria below for comorbid exclusions	> 3 yrs No comorbid conditions	All patients < 3 yr or > 3 yrs with comorbid conditions BMI > 35
Selection Criteria	ASC Patient Selection Policy ASC Patient Selection Guidelines Job Aid	KOPH Anesthesia: Patient Selection Criteria Policy
Polysomnography Results	Apnea/Hypopnea Index (AHI) 0-23 and No high-risk gas exchange concerns Peak CO₂ ≤ 55, O₂ nadir ≥ 90 85-89% with approval from ASC medical director	AHI > 23 and High-risk gas exchange concerns Peak CO₂ ≥ 60, O₂ nadir ≤ 85	AHI 0-23 and No high-risk gas exchange concerns Peak CO₂ ≤ 60, O₂ nadir ≥ 85	AHI > 23 and High-risk gas exchange concerns Peak CO₂ ≥ 60, O₂ nadir ≤ 85

Ambulatory Surgery Center

PHL or KOPH Day Surgery

PHL or KOPH Inpatient

Post-Surgery/Perianesthesia Care Unit
Determine Disposition

ASC and Day Surgery Discharge Criteria

Discharge Instructions

Inpatient Surgical Unit

PICU

SPIT Discharge Criteria

Minimum Fluid Intake Guidance

Discharge Instructions

Posted: July 2016
Last Revised: April 2025

Authors:
- T. Giordano, DNP;
- L. Elden, MD;
- H. Wolfe, MD;
- L. Schera, RN;
- E. Carroll, RN;
- B. Hansell, RN;
- A. Simpao, MD

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Inpatient and Outpatient Specialty Care Clinical Pathway to Triage Tonsillectomy and/or Adenotonsillectomy Patients with or without Preoperative Polysomnography

Evidence