The Epsom children's ENT day-case anaesthetic protocol for tonsillectomy reports a 98% same-day discharge rate . We congratulate the authors' success in applying a multifactorial strategy combining psychological, pharmacological and physical approaches to optimise peri-operative care. We have two comments and one suggestion.
Our first comment arises from the list of interventions in their Table 1 . Although not explicitly stated, the list appears to be presented in sequential order. If so, ondansetron was given at induction of anaesthesia followed by dexamethasone. A major multinational guideline has been published on the management of postoperative nausea and vomiting . In this, the advice for cases requiring more than one anti-emetic (such as tonsillectomy) is to give dexamethasone first, before surgery, followed by another anti-emetic (such as ondansetron, which is licensed for use in children) after completion of surgery. Our second comment arises from the choice of sevoflurane for maintenance of anaesthesia. Use of sevoflurane in paediatric anaesthesia is reported to carry a greater incidence of postoperative emergence delerium compared with other volatile agents . Isoflurane is a reasonable, and cheaper, alternative.
Our suggestion is that use of ‘low dose’ ketamine could be included in the anaesthetic sequence. For paediatric tonsillectomy, pre-operative ketamine has been given as intravenous (0.5 mg.kg−1)  and intramuscular (0.1 mgkg−1)  doses as part of a balanced anaesthetic sequence with reports of improved pain control without the well-known complications attributed to ketamine. Whilst these positive findings have not always been repeated , we believe that ‘low dose’ ketamine has the potential to enhance analgesic management in selected procedures.