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Kou YF, Korpon JR, Dabbous H, Johnson RF, Mitchell RB, Wani A, Chorney SR. Postoperative Respiratory Complications After Adenotonsillectomy in Children With High-Risk Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2024. [PMID: 39194366 DOI: 10.1002/ohn.961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 08/01/2024] [Accepted: 08/18/2024] [Indexed: 08/29/2024]
Abstract
OBJECTIVE Identify patient characteristics and polysomnogram (PSG) parameters associated with postoperative respiratory complications after adenotonsillectomy (AT) among children with high-risk obstructive sleep apnea (OSA). STUDY DESIGN Case series with chart review. SETTING Tertiary care children's hospital. METHODS Pediatric patients (<18 years) with high-risk OSA (any 1 of: apnea-hypopnea index [AHI] >30, O2 nadir <80% and peak CO2 >60 mm Hg) on overnight PSG from 2019 to 2021 were included. Primary outcomes were major respiratory intervention during the postoperative admission, prolonged hospitalization, and intensive care unit (ICU) stay. RESULTS A total of 307 patients met inclusion criteria. Median age was 6.5 years and 63% were male. Twenty-five (8.1%) required major respiratory intervention and 29 (9.7%) required ICU admission after AT. Major interventions and ICU admissions were significantly associated with neuromuscular disease (P < .01), higher obstructive apnea-hypopnea index (oAHI), higher CO2 peak, and lower O2 nadir. Prolonged admission had similar findings except oAHI was not significantly associated. Younger children were significant more likely to require ICU admission or prolonged admission. CONCLUSION Increased oAHI and worsening O2 and CO2 parameters on preoperative PSG were associated with postoperative respiratory complications in children with high-risk OSA. Children with neuromuscular disease and age 0 to 2 had higher risk of ICU stay and prolonged hospitalization. Clinicians should recognize the importance of parameters beyond oAHI when anticipating postoperative monitoring.
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Affiliation(s)
- Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health Medical Center Dallas, Dallas, Texas, USA
| | - Jonathan R Korpon
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Helene Dabbous
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health Medical Center Dallas, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health Medical Center Dallas, Dallas, Texas, USA
| | - Ron B Mitchell
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health Medical Center Dallas, Dallas, Texas, USA
| | - Anna Wani
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's Health Medical Center Dallas, Dallas, Texas, USA
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Park AC, Billings K, Maddalozzo J, Dsida R, Benzon HA, Lavin J, Hazkani I. Perioperative opioids in high-risk children undergoing tonsillectomy - A single institution experience. Am J Otolaryngol 2024; 45:104453. [PMID: 39151380 DOI: 10.1016/j.amjoto.2024.104453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/29/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Patients undergoing tonsillectomy/ adenotonsillectomy (T/AT) can experience substantial postoperative pain. The aims of this study are to assess perioperative pain management in high-risk children (children with severe obstructive sleep apnea and other complex medical comorbidities or age younger than 2 years) undergoing T/AT, and the impact on oxygen levels and pain during extended Post-Anesthesia Care Unit (PACU) admission. METHODS A retrospective case series study at a tertiary care children's hospital. RESULTS There were 278 children enrolled in the study. The Apnea-Hypopnea index and mean oxygen nadir on preoperative polysomnography were 31.3 ± 25.76/h and 79.5 ± 9.5 % respectively. Overall, 246 (89 %) patients received intraoperative opioids alone (n = 35, 13 %) or in combination with non-opioid analgesia (n = 209, 75 %). While the median dose of opioid-free medications (acetaminophen, ibuprofen) ranged from 93 to 100 % of standard maximal dosing by weight and age, the median dose of opioids was significantly lower and ranged from 54 to 63 % of standard maximal dosing by weight and age, with 43 % of the patients receiving less than half the recommended maximum dose. Oxygen desaturation was charted in 21 patients (8 %) during their PACU admission. Patients who received opioid-free analgesia were as likely to develop oxygen desaturations (n = 17 (81 %) vs. n = 228 (89.4 %), p = 0.27) and to receive rescue pain medication during their PACU stay as patients who received opioids intraoperatively (n = 18 (56 %) vs. n = 167 (68 %), p = 0.23). CONCLUSIONS Intraoperative pain management varies across high-risk pediatric tonsillectomies. Opioid-free analgesia was not associated with an increased need for pain medications during PACU admission, or with a decreased likelihood of oxygen desaturations compared to intra-operative opioid analgesia use.
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Affiliation(s)
- Asher C Park
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kathleen Billings
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - John Maddalozzo
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Richard Dsida
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Hubert A Benzon
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jennifer Lavin
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Inbal Hazkani
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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Efune PN, Pinales P, Park J, Poppino KF, Mitchell RB, Szmuk P. Pediatric obstructive sleep apnea: a prospective observational study of respiratory events in the immediate recovery period after adenotonsillectomy. Anaesth Crit Care Pain Med 2024; 43:101385. [PMID: 38705239 DOI: 10.1016/j.accpm.2024.101385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Adenotonsillectomy is often curative for pediatric obstructive sleep apnea, yet children remain at high risk of respiratory complications in the postoperative period. We sought to determine the incidence and risk factors for respiratory depression and airway obstruction, as well as clinically apparent respiratory events in the post-anesthesia care unit (PACU) in high-risk children after adenotonsillectomy. METHODS In this prospective cohort study, we enrolled 60 high-risk children having adenotonsillectomy. Our primary outcome was respiratory depression and airway obstruction in the PACU measured using a noninvasive respiratory volume monitor (RVM) and defined by episodes of predicted minute ventilation less than 40% for at least 2 min. We measured clinically apparent respiratory events using continuous observation by trained study staff. RESULTS The median (range) age of our sample was 4 years (1, 16) and 27 (45%) were female. Black and Hispanic race children comprised 80% (n = 48) of our cohort. Thirty-nine (65%) had at least one episode of PACU respiratory depression or airway obstruction measured using the RVM, while only 21 (35%) had clinically apparent respiratory events. Poisson regression demonstrated the following associations with an increase in episodes of respiratory depression and airway obstruction: BMI Z-score less than -1 (estimate 3.91; [95%CI 1.49-10.23]), BMI Z-score 1-2 (estimate 2.04; [1.20-3.48]), and two or more comorbidities (estimate 1.96; [1.11-3.46]). CONCLUSIONS Respiratory volume monitoring in the immediate postoperative period after pediatric high-risk adenotonsillectomy identifies impaired ventilation more frequently than is clinically apparent.
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Affiliation(s)
- Proshad N Efune
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States; Outcomes Research Consortium, 9500 Euclid Avenue Cleveland, OH 44195, United States.
| | - Pedro Pinales
- University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-8876, United States.
| | - Jenny Park
- Southern Methodist University, Department of Biostatistics, 6425 Boaz Lane, Dallas TX 75205, United States.
| | - Kiley F Poppino
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States
| | - Ron B Mitchell
- University of Texas Southwestern Medical Center, Department of Otolaryngology, Head and Neck Surgery, 2001 Inwood Road, Dallas, TX 75390-9035, United States.
| | - Peter Szmuk
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States; Outcomes Research Consortium, 9500 Euclid Avenue Cleveland, OH 44195, United States.
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Liu K, Liu C. In Response to Is Polysomnography Both Reliable and Accessible to Predict Respiratory Events. Laryngoscope 2023. [PMID: 36815618 DOI: 10.1002/lary.30603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Katie Liu
- Department of Anesthesiology, Pediatric Anesthesiology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, USA
| | - Christopher Liu
- Department of Otolaryngology, Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Health Dallas, Dallas, Texas, USA
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Onal M, Onal O. Is Polysomnography Both Reliable and Accessible to Predict Respiratory Events? Laryngoscope 2023. [PMID: 36815615 DOI: 10.1002/lary.30604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 02/24/2023]
Affiliation(s)
- Merih Onal
- Department of Otorhinolaryngology, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Ozkan Onal
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Main Hospital, Cleveland, Ohio, USA.,Department of Anesthesiology and Reanimation, Selcuk University Faculty of Medicine, Konya, Turkey
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Onal O, Onal M. Critical Strategies to Prevent Pediatric Post-tonsillectomy Respiratory Complications. Laryngoscope 2023. [PMID: 36815594 DOI: 10.1002/lary.30600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 02/24/2023]
Affiliation(s)
- Ozkan Onal
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Main Hospital, Cleveland, Ohio, USA.,Department of Anesthesiology and Reanimation, Selcuk University Faculty of Medicine, Konya, Selcuklu, Turkey
| | - Merih Onal
- Department of Otorhinolaryngology, Selcuk University Faculty of Medicine, Konya, Selcuklu, Turkey
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Clinical Characteristics and Post-Operative Outcomes in Children with Very Severe Obstructive Sleep Apnea. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9091396. [PMID: 36138705 PMCID: PMC9498166 DOI: 10.3390/children9091396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/06/2022] [Accepted: 09/10/2022] [Indexed: 11/17/2022]
Abstract
Available information on clinical characteristics and post-operative outcomes in children with very severe obstructive sleep apnea (OSA) is limited. Our study evaluates the clinical features and polysomnographic (PSG) variables that predict post-operative outcomes in children with an obstructive apneal hypopnea index (AHI) of more than 25 events/hr. In this study from a single tertiary care center, we performed a retrospective chart review of patients with an AHI > 25/hr, who underwent tonsillectomy and adenoidectomy (T&A) between January 2016 and September 2021. In total, 50 children were included in the study: 26.0% (13/50) of children experienced post-operative respiratory events and four children needed intubation and ventilator support. Compared with children without respiratory events, children requiring post-operative respiratory interventions were younger (4.4 ± 5.2 vs. 8.0 ± 5.2 years; p = 0.04), had higher pre-operative AHI (73.6 ± 27.4 vs. 44.8 ± 24.9; p < 0.01), lower oxygen nadirs (70.0 ± 13.0% vs. 83.0 ± 7.0%; p < 0.01), and had lower body metabolic index Z-scores (−0.51 ± 2.1 vs. 0.66 ± 1.5; p < 0.04). Moderate to severe residual OSA was identified in 70% (24/34) of children with available post-operative PSG; younger children had better PSG outcomes. Our study shows that post-operative respiratory events are frequent in children with very severe OSA, particularly with an AHI > 40/h, younger children (<2 years of age), lower oxygen saturation (SpO2), and poor nutritional status, necessitating close monitoring.
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