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Microsoft word - d-postop t a 1-30-2013 (2)
Dr. Donovan’s Postoperative Instructions for
Tonsillectomy, Adenoidectomy and UPP 1-30-2013
Activity Level: Light activity and adequate rest are recommended for the first few days. Sleeping with the head elevated 30–45 degrees or in a recliner for 3–4 days will reduce the swelling in the throat. The uvula (the thing that hangs down from the palate) can be swollen for the first few days and touch the tongue, occasionally causing a gagging sensation. Patients are encouraged to get up and walk around the house several times a day to maintain circulation in their legs. Children should be under close supervision by a responsible adult. Children who have had an adenoidectomy without a tonsillectomy may have a shorter recovery time. Bad Breath: When the tonsils or adenoid are removed a white or yellow/tan protective layer develops. The mouth’s bacteria will settle on this layer and produce bad breath (halitosis). As healing occurs, this layer sloughs off and the bad breath resolves. ANTIBIOTICS ARE NOT NEEDED. Bleeding: Bleeding may occur anytime during the 2–3 week healing period. Minor bleeding is often self-limited. A small amount of blood will turn the patient’s saliva red, but will not produce large clots. Encourage the patient to gargle with cool water and spit it out. Please avoid swallowing the blood as this will often result in nausea or vomiting. Spitting the blood into a bowl will let one estimate the amount of blood. Call the office if the light bleeding does not stop in ten minutes. If significant bleeding occurs, start the water gargles, and come to either our office during office hours or to the Emergency Room at Salem Hospital after office hours. Breathing Exercises: Every 15–30 minutes while awake, have the patient take a deep breath in and cough once or twice to expand and clear the lungs. Also try to have the patient take at least 5-10 minute walks every 2-3 hours during the day. They may go outside. This helps prevent fever. Fever: The patient’s temperature is frequently elevated up to 102o F. To minimize the elevation please:
1. Encourage the “breathing exercises” and walking described above. 2. Take the full acetaminophen and/or ibuprofen doses listed on the bottle. Please follow the bottle’s
guidelines using your patient’s weight. OVERDOSES OF THESE DRUGS CAN LEAD TO LIVER AND/OR KIDNEY PROBLEMS.
3. Encourage adequate fluid intake. If the patient’s temperature remains above 102o F one hour after
receiving a full dose of acetaminophen/ibuprofen, please call our office in the morning for further instructions.
Fluids and Diet: Adequate fluid intake is essential for recovery. Encourage drinking fluids throughout the day. Extreme temperature or acidic (e.g. grapefruit, tomato juice) liquids may hurt. Popsicles are often a good source of fluid. Older children and adults may chew sugarless gum to promote swallowing and decrease pain. The patient should drink enough to urinate every 3-4 hours. The urine should be clear to light yellow. If the patient urinates only small amounts of dark yellow urine, then he/she is showing signs of dehydration. You should push more crushed ice and fluids. Call the office if there is no improvement over the next 3-4 hours. Nausea and Vomiting: Nausea and vomiting are common during the first 24 hours after surgery. Narcotic medication may increase the nausea and vomiting. Please try to reduce the narcotic pain medicine as much as possible, either by reducing the amount given or lengthening the time between doses. One may try to skip one dose of narcotic and use just a full dose of plain acetaminophen (e.g. Tylenol ) or ibuprofen (e.g. Motrin). The patient may also try to eat some simple, non-fatty food with the next dose of narcotics. If the vomiting persists after trying these steps, please call our office. An anti-nausea medication may be given. THESE ARE SEDATING. TAKE ONE ANTI-NAUSEA PILL 30 MINUTES BEFORE THE PAIN MEDICINE. MAKE SURE THAT THE PATIENT DRINKS 30-60 MINUTES AFTER THE PAIN MEDICINE IS GIVEN TO STAY HYDRATED. Try to minimize the
combined use of anti-nausea medication and narcotics in patients with severe snoring or sleep apnea. Closely monitor the patient’s breathing for the next 3-4 hours. Ear pain: Some patients experience pain that is referred to one or both ears. This ear pain may be as severe as the throat pain and longer lasting. The patient may treat this using the same guidelines listed below for the throat pain. Please call our office in the morning if hearing loss is noted or the patient has pus-like ear drainage (unless they had ear tubes placed, and the patient is already on an ear medication). Nose Blowing: You can blow your nose lightly with your mouth open to clear nasal secretions. Rinsing each nostril with saline spray may help to loosen the mucus and ease blowing. Saline spray is sold “over the counter” at pharmacies. Oral Hygiene: You may brush and floss your teeth as usual. Avoid mouthwashes that contain alcohol or peroxide. Do not routinely gargle vigorously after a tonsillectomy. The bad breath may persist. CONSTIPATION: PATIENTS MAY EXPERIENCE CONSTIPATION WHILE TAKING NARCOTICS AND EATING A LOW FIBER DIET. PLEASE TRY TO MINIMIZE NARCOTICS USING THE GUIDELINES BELOW. ALSO TRY TO EAT SOME SOFT FOODS WITH FIBER: E.G. APPLE SAUCE, BANANAS and BERRIES. ONE CAN BLEND SOME FRUITS WITH ICE FOR A COOL “SMOOTHIE” DRINK. CPAP: If the patient is using CPAP, BiPAP, or supplemental oxygen before surgery, then he/she should continue this during ANY SLEEPING OR NAPPING during the recovery period until instructed by the surgeon to stop. Surgery causes swelling in the throat that can temporarily worsen any airway obstruction. Sitting up in a recliner while sleeping will reduce this swelling. If the patient feels that he/she is not getting enough air, you may try Afrin nasal sprays before bedtime for the first week only. Call the office if this does not work. Pain Management: A realistic goal is to reduce the patient’s pain to a manageable level, not to eliminate the pain. One cannot predict a patient’s pain level or the necessary dose of pain medicine. One must approach each patient in a stepwise fashion for pain management. Specifically, when acetaminophen and/or ibuprofen do not lower the pain enough, then start with a lower dose of narcotic, and increase the dose if pain remains uncontrolled, or decrease the dose if the medication’s side effects are too severe. Close monitoring of each patient for side effects of each medication is essential.
1. Try to use plain acetaminophen or plain ibuprofen before using the narcotics. 2. Always strive to either avoid the narcotics or give the lowest dose possible to control the pain. 3. Give the narcotic AS NEEDED but not more often than it states on the bottle 4. Do not give the narcotics “automatically around the clock” if the patient has minimal pain. 5. Never wake up a sleeping patient to give them narcotics 6. Avoid combining narcotics with another sedating drug: e.g. alcohol, sleeping pills, MUSCLE
RELAXANTS or anti-anxiety pills (e.g. Valium and Xanax), antihistamines (e.g. Benadryl) unless instructed by your doctor.
7. Start with the lower dose that is prescribed, and take additional medication only if the pain is still
not adequately controlled 45 minutes after taking the first dose. For example, if the prescription reads “10 – 20 mL every 4 – 6 hours as needed for pain”, then start with 10 mL of pain medicine on the first dose. If the pain is not adequately controlled in 45 minutes, then add 10 mL more for a total dose of 20 mL. . 8. Every day try to decrease the total amount of narcotic medication given, by:
a. increasing the time between doses, or b. decreasing the amount used each time, or c. substituting plain acetaminophen or ibuprofen for the narcotic
9. Observe for unusual sleepiness, confusion, difficult or noisy breathing. If these occur, then stop
all narcotics, call WENT MD on call at 503-581-1567 or go to Salem Emergency Room if the office is closed.
10. Always measure the amount of liquid narcotic with a syringe or a marked medicine cup. Spoon
11. Record the medication given with the date and time on the same piece of paper. This helps
Step 1: Acetaminophen (Tylenol) can decrease both pain and fever. The medication usually lasts for 3–4 hours. It is often combined with narcotics. It may be given orally as a liquid or pill or rectally (a suppository). One may wake a patient up after 4 hours and give him/her another dose of plain acetaminophen without fear of overly sedating them. One must add the plain acetaminophen to the amount in a narcotic combination (e.g. acetaminophen with codeine or HYDROcodone with acetaminophen) when calculating the maximum next dose. For example: if the patient can have 10 ml of acetaminophen every 4 hours: then they may take 5 ml of plain acetaminophen and 5 ml of HYDROcodone/acetaminophen. Some patients who experience recurrent nausea or vomiting with narcotics do better using just plain acetaminophen or ibuprofen for pain relief. Step 2: Ibuprofen (Motrin, Advil) may last for 6-8 hours. It comes in liquid and pill form. Please use the instructions on the bottle for the dosing. Ibuprofen is a good pain reliever and fever reducer. Unfortunately, it may contribute to bleeding in a few patients. If the patient experiences moderate or severe bleeding, then stop the ibuprofen for at least 24 hours. Step 3: Narcotics: Acetaminophen with HYDROcodone (Lortab) or Acetaminophen with oxyCODONE
(Percocet) are two commonly used narcotics. HYDROmorphone (Diluadid) can be used by adult patients.
Step 4: Carafate: This may coat the tonsil area and decrease the pain. The adult dose is 10 ml orally, gargle and swallow up to 4 times a day. It can cause constipation.
General Acetaminophen or Lortab starting guidelines: Total daily dosage for children NOT to exceed 6 doses per day.
A. Using the above guidelines (page 3), please start with:
Step 1: ____ ml of acetaminophen elixir (160mg/5ml) every 4-6 hours. Step 2: ibuprofen every 6 hours (5 mg/kg). One must follow the bottle’s dosing instructions based on your child’s weight. It is ok to alternate between Step 1 and Step 2. For example give plain acetaminophen at 8 am, then ibuprofen at 11 am, then plain acetaminophen at 2 pm, then ibuprofen at 5 pm, etc.
Step 3: ____ ml of hydrocodone 2.5/acetaminophen 167/5ml using the LOWER DOSE on the chart WITH
____ ml of acetaminophen elixir (160mg/5ml) every 4-6 hours.
It is ok to alternate between Step 3 and Step 2. For example give Step 3 at 8 am, then ibuprofen at 11 am, then Step 3 at 2 pm, then ibuprofen at 5 pm, etc. Step 4: ____ ml of hydrocodone 2.5/acetaminophen 167/5ml using the HIGHER DOSE on the chart. It is ok to alternate between Step 4 and Step 2. For example give Step 4 at 8 am, then ibuprofen at 11 am, then Step 4 at 2 pm, then ibuprofen at 5 pm, etc.
ONE MUST USE A SYRINGE OR DROPPER WITH ml MARKINGS. DO NOT USE SPOONS TO MEASURE. THEY ARE TOO VARIABLE IN SIZE. SYRINGES CAN BE PURCHASED AT PHARMACIES OR REQUEST ONE FROM OUR OFFICE.
B. Pill option (do not combine this with any other narcotics, including the steps 3&4 above):
____ tablets/suppositories of acetaminophen ______ mg AND / OR
____ tablets of _____ mg HYDROcodone with acetaminophen
____ tablets of _____ mg oxyCODONE with acetaminophen
____ tablets of _____ mg hydromorphone (1-4 mg every 4 hours for adults; use the lowest
Adjust the doses up or down depending on the patients’ reaction and pain level 45-60 minutes later. SOME NARCOTICS CAN ACCUMULATE OVER TIME. EACH DAY TRY TO USE A LOWER DOSE OR INCREASE THE TIME BETWEEN DOSES. ALWAYS MONITOR THE PATIENT FOR SLOWED BREATHING, EXCESSIVE SLEEPINESS, INCOORDINATION.
TO AVOID RUNNING OUT OF A NARCOTIC MEDICATION:
1. Please fill your narcotic prescriptions at a pharmacy that is open after hours and on weekends. Use the same pharmacy; narcotic prescriptions cannot be transferred between pharmacies. 2. Call our office by 2 pm the day BEFORE you will need a refill to give us time to process your request. SOME FAMILY MEMBER WILL NEED TO DRIVE TO OUR OFFICE TO PICK UP THE NARCOTIC PRESCRIPTION (DEA RULES). IF YOU ARE TAKING NARCOTICS, YOU CANNOT DRIVE. YOU COULD BE CITED FOR “DRIVING UNDER THE INFLUENCE”.
Other Questions: For non-emergent questions, please call our office (503-581-1567) between 9:00 am and 3:00 pm. Monday through Friday. For emergent question, please call our office (503-581-1567), and our answering service will page the doctor on call. We have a doctor on call 7 days a week.
THERAPEUTIC USE EXEMPTION FOR ASTHMA Excerpts taken from WADA’s Medical Information to Support the Decisions of TUECs for Asthma, Version 5.0 January 2013 Since January 01, 2010, a TUE is no longer required for the use of salbutamol* and salmeterol taken by inhalation as they were removed from the Prohibited List. Additionally, as of January 01, 2013, inhaled formoterol up to a ma
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