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Rossi NA, Spaude J, Ohlstein JF, Pine HS, Daram S, McKinnon BJ, Szeremeta W. Apnea-hypopnea index severity as an independent predictor of post-tonsillectomy respiratory complications in pediatric patients: A retrospective study. EAR, NOSE & THROAT JOURNAL 2024; 103:424-429. [PMID: 34851765 DOI: 10.1177/01455613211059468] [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] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Despite the presence of clinical practice guidelines for overnight admission of pediatric patients following adenotonsillectomy, variance in practice patterns exists between pediatric otolaryngologists. The purpose of this study is to examine severity of apnea-hypopnea index (AHI) as an independent predictor of postoperative respiratory complications in children undergoing adenotonsillectomy. METHODS Retrospective chart review of all children undergoing adenotonsillectomy at a large tertiary referral center between January 2015 and December 2019 who underwent preoperative polysomnography and were admitted for overnight observation. Charts were reviewed for total adverse events and respiratory events occurring during admission. RESULTS Overall, respiratory events were seen in 50.6% of patients with AHI ≥10 and in 39.6% of patients with AHI <10. The overall mean AHI was 19.2, with a mean of 28.1 in the AHI ≥10 subgroup vs 4.6 in the AHI <10 subgroup. There was no statistical correlation or increased risk between an AHI ≥10 and having a pure respiratory event, with a relative risk of 1.19 (.77-1.83, P = .43). There was a statistically significant difference between the mean AHI of those with any adverse event and those without (21.6 vs 13.4, P = .008). There is additionally an increased risk of any event with an AHI over 10, with a relative risk of 1.51 (1.22-1.88, P < .0001). CONCLUSION Preoperative AHI of 10 events per hour was not a predictor of postoperative respiratory complications. However, there was a trend for those with a higher AHI requiring additional supportive measures or a prolonged stay. Practitioners should always use their best judgment in deciding whether a child warrants postoperative admission following adenotonsillectomy.
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Affiliation(s)
- Nicholas A Rossi
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jordan Spaude
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jason F Ohlstein
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Harold S Pine
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Shiva Daram
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Brian J McKinnon
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
| | - Wasyl Szeremeta
- Department of Otolaryngology, University of Texas Medical Branch, Galveston, TX, USA
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Knio ZO, Zhang L, Watts DA, Zuo Z. Late surgical start time is associated with increased blood transfusion following gastric bypass surgery. PLoS One 2023; 18:e0282139. [PMID: 36827326 PMCID: PMC9956042 DOI: 10.1371/journal.pone.0282139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/08/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Surgical start time (SST) has demonstrated conflicting effects on perioperative outcomes due to confounding factors, such as increased acuity in later SST cases. This study investigated the effect of SST on blood transfusion after gastric bypass surgery, a complication-prone elective surgical procedure. METHODS This retrospective cohort study included all patients undergoing gastric bypass surgery at a single academic medical center from 2016 through 2021 (n = 299). The primary independent variable was SST (before vs. after 15:00). The primary outcome was blood transfusion. Secondary outcomes included postoperative respiratory failure, length of stay, acute kidney injury, and mortality. The associations between SST and outcomes were investigated with univariate analyses. Multivariate and receiver operating characteristic (ROC) analyses were applied to the primary outcome, adjusting for demographic and operative characteristics. RESULTS On univariate analysis, 15:00-18:43 SST was associated with an increased risk of blood transfusion (relative risk 4.32, 95% confidence interval 1.27 to 14.63, p = 0.032), but not postoperative respiratory failure, acute kidney injury, length of stay, or mortality. On multivariate analysis, the only independent predictor of postoperative blood transfusion was a 15:00-18:43 SST (adjusted odds ratio 4.32, 95% confidence interval 1.06 to 15.96, c-statistic = 0.638). ROC analysis demonstrated that compared to the 15:00 threshold, a 14:34 threshold predicted postoperative blood transfusion with better accuracy (sensitivity = 70.0%, specificity = 83.0%). CONCLUSIONS Despite having similar demographic and operative characteristics, gastric bypass patients in the late SST cohort had a greater incidence of postoperative blood transfusion in this single-center study.
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Affiliation(s)
- Ziyad O. Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
| | - Lena Zhang
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
| | - David A. Watts
- School of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
- * E-mail:
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Rollins JT, Wajsberg B, Bitners AC, Burton WB, Hametz PA, Chambers TA, Yang CJ. Admission practices following pediatric tonsillectomy: A survey of ASPO members. Int J Pediatr Otorhinolaryngol 2022; 162:111286. [PMID: 36206700 PMCID: PMC11232560 DOI: 10.1016/j.ijporl.2022.111286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/08/2022] [Accepted: 08/12/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Although evidence-based Clinical Practice Guidelines (CPGs) have specified postoperative admission criteria for pediatric tonsillectomy, there is substantial variation in guideline implementation and adherence among otolaryngologists in practice. We aimed to assess pediatric otolaryngologists' post-tonsillectomy admission practices and to examine patient and surgeon factors associated with differences in admission practices. METHODS An electronic cross-sectional survey was distributed to members of the American Society of Pediatric Otolaryngology (ASPO) to determine current practices regarding admission practices following pediatric tonsillectomy. Chi-square and Fisher's exact tests were performed to compare differences in adherence to tonsillectomy CPGs by respondent characteristics. RESULTS The survey was sent to 644 pediatric otolaryngologists with a response rate of 19.1%. 37% of respondents reported "always" and 60% "often" using the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) CPG to guide decision for admission. Years in practice was the factor most strongly associated with admission practices, with 10 or fewer years in practice significantly correlated with stricter adherence to the AAO-HNS CPG of overnight observation when Apnea-Hypopnea Index (AHI) ≥10, age <3 years, or O2 nadir <80%) (OR 4.2, p <0.001), as well as specific individual criteria such as an AHI ≥10 (OR 4.1, p = 0.03). Respondents in an academic practice setting were more likely to admit children <3 years of age than those in private practice (OR 5.0, p = 0.01). CONCLUSION Admission practices varied among pediatric otolaryngologist survey respondents, and strict AAO-HNS CPG adherence was associated with fewer years in practice and academic practice setting. These results suggest that further study investigating factors influencing guideline adherence and post-tonsillectomy admission practices is warranted.
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Affiliation(s)
| | | | - Anna C Bitners
- Johns Hopkins Hospital, Department of Pediatrics, Baltimore, MD, USA
| | | | - Patricia A Hametz
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Pediatrics, Bronx, NY, USA
| | - Terry-Ann Chambers
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Anesthesiology, Bronx, NY, USA
| | - Christina J Yang
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Pediatrics, Bronx, NY, USA; Montefiore Medical Center, Department of Otorhinolaryngology-Head and Neck Surgery, Bronx, NY, USA.
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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5
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MacLean JE. Assessment and treatment of pediatric obstructive sleep apnea in Canada: history and current state of affairs. Sleep Med 2019; 56:23-28. [PMID: 30745075 DOI: 10.1016/j.sleep.2019.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/04/2019] [Accepted: 01/06/2019] [Indexed: 02/07/2023]
Abstract
AIM To highlight Canada's contributions to the assessment and treatment of pediatric obstructive sleep apnea as well as outline the current state of pediatric obstructive sleep apnea in Canada. METHODS A search was conducted in MEDLINE (Ovid) using Medical Subject Headings (MeSH) and free-text terms for 'child' and 'obstructive sleep apnea' with subsequent 'human' limit. The results were reviewed to identify publications where any author's listed a Canadian institution. RESULTS Canadian contributions to the field of pediatric obstructive sleep apnea have grown over the last 30 years with an increase in number of contributors and centres. Much of the early work stemmed from McGill University with important contributions in examining alternatives to polysomnography and post-adenotonsillectomy respiratory compromise. Today, contributors from centres across the country are engaged in the field and come from a greater diversity of disciplines. With continued challenges and opportunities, Canada will continue to help advance the field of pediatric OSA. CONCLUSION Canada has a strong community of people invested in continuing to work to improve the lives of Canadian children with pediatric OSA.
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Affiliation(s)
- Joanna E MacLean
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Women & Children's Health Research Institute, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Stollery Children's Hospital, Edmonton, Alberta, Canada.
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Thavagnanam S, Cheong SY, Chinna K, Nathan AM, de Bruyne JA. Pre-operative parameters do not reliably identify post-operative respiratory risk in children undergoing adenotonsillectomy. J Paediatr Child Health 2018; 54:530-534. [PMID: 29168911 DOI: 10.1111/jpc.13789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/09/2017] [Accepted: 09/16/2017] [Indexed: 11/28/2022]
Abstract
AIM Adenotonsillectomy is performed in children with recurrent tonsillitis or obstructive sleep apnoea. Children at risk of post-operative respiratory complications are recommended to be monitored in paediatric intensive care unit (PICU). The aim of the study is to review the risk factors for post-operative complications and admissions to PICU. METHODS A review of medical records of children who underwent adenotonsillectomy between January 2011 and December 2014 was performed. Association between demographic variables and post-operative complications were examined using chi-square and Mann-Whitney tests. RESULTS A total of 214 children were identified, and of these, 19 (8.8%) experienced post-operative complications. Six children (2.8%) had respiratory complications: hypoxaemia in four and laryngospasm requiring reintubation in a further two. Both of the latter patients were extubated upon arrival to PICU and required no escalation of therapy. A total of 13 (6.1%) children had non-respiratory complications: 8 (3.7%) had infection and 5 (2.3%) had haemorrhage. A total of 26 (12.1%) children were electively admitted to PICU and mean stay was 19.5 (SD ± 13) h. No association between demographic characteristics, comorbid conditions or polysomnographic parameters and post-operative complications were noted. A total of 194 (90.7%) children stayed only one night in hospital (median 1 day, range 1-5 days). CONCLUSION The previously identified risk factors and criteria for PICU admission need revision, and new recommendations are necessary.
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Affiliation(s)
- Surendran Thavagnanam
- Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia.,University Malaya Paediatric and Child Health Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Saou Y Cheong
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Karuthan Chinna
- Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Anna M Nathan
- Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia.,University Malaya Paediatric and Child Health Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Jessie A de Bruyne
- Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia.,University Malaya Paediatric and Child Health Research Group, University of Malaya, Kuala Lumpur, Malaysia
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Konstantinopoulou S, Gallagher P, Elden L, Garetz SL, Mitchell RB, Redline S, Rosen CL, Katz ES, Chervin RD, Amin R, Arens R, Paruthi S, Marcus CL. Complications of adenotonsillectomy for obstructive sleep apnea in school-aged children. Int J Pediatr Otorhinolaryngol 2015; 79:240-5. [PMID: 25575425 PMCID: PMC4319650 DOI: 10.1016/j.ijporl.2014.12.018] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/14/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Adenotonsillectomy is the treatment of choice for most children with obstructive sleep apnea syndrome, but can lead to complications. Current guidelines recommend that high-risk children be hospitalized after adenotonsillectomy, but it is unclear which otherwise-healthy children will develop post-operative complications. We hypothesized that polysomnographic parameters would predict post-operative complications in children who participated in the Childhood AdenoTonsillectomy (CHAT) study. METHODS Children in the CHAT study aged 5-9 years with apnea hypopnea index 2-30/h or obstructive apnea index 1-20/h without comorbidities other than obesity/asthma underwent adenotonsillectomy. Associations between demographic variables and surgical complications were examined with Chi square and Fisher's exact tests. Polysomnographic parameters between subjects with/without complications were compared using Mann-Whitney tests. RESULTS Of the 221 children (median apnea hypopnea index 4.7/h, range 1.2-27.7/h; 31% obese), 16 (7%) children experienced complications. 3 (1.4%) children had respiratory complications including pulmonary edema, hypoxemia and bronchospasm. Thirteen (5.9%) had non-respiratory complications, including dehydration (4.5%), hemorrhage (2.3%) and fever (0.5%). There were no statistically significant associations between demographic parameters (gender, race, and obesity) or polysomnographic parameters (apnea hypopnea index, % total sleep time with SpO2<92%, SpO2 nadir, % sleep time with end-tidal CO2>50Torr) and complications. CONCLUSIONS This study showed a low risk of post-adenotonsillectomy complications in school-aged healthy children with obstructive apnea although many children met published criteria for admission due to obesity, or polysomnographic severity. In this specific population, none of the polysomnographic or demographic parameters predicted post-operative complications. Further research could identify the patients at greatest risk of post-operative complications.
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Affiliation(s)
- Sofia Konstantinopoulou
- Department of Pediatrics, Sleep Center, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States.
| | - Paul Gallagher
- Biostatistics Core, The Clinical and Translational Research Center, Children’s Hospital of Philadelphia; University of Pennsylvania, Philadelphia, PA
| | - Lisa Elden
- Department of Otolaryngology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Susan L. Garetz
- Department of Otolaryngology, University of Michigan, Ann Arbor, MI
| | - Ron B. Mitchell
- Departments of Otolaryngology and Pediatrics, UT Southwestern Medical Center, Dallas, TX
| | - Susan Redline
- Department of Medicine, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Carol L. Rosen
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH
| | - Eliot S. Katz
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Ronald D. Chervin
- Departments of Pediatrics and Neurology, University of Michigan, Ann Arbor, MI
| | - Raouf Amin
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Raanan Arens
- Department of Pediatrics, Children’s Hospital at Montefiore and Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Shalini Paruthi
- Department of Pediatrics and Internal Medicine, Cardinal Glennon Children’s Medical Center, Saint Louis University, St Louis, MO
| | - Carole L. Marcus
- Department of Pediatrics, Sleep Center, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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Abstract
Obstructive sleep apnea syndrome (OSAS) is a disorder of airway obstruction with multisystem implications and associated complications. OSAS affects children from infancy to adulthood and is responsible for behavioral, cognitive, and growth impairment as well as cardiovascular and perioperative respiratory morbidity and mortality. OSAS is associated commonly with comorbid conditions, including obesity and asthma. Adenotonsillectomy is the most commonly used treatment option for OSAS in childhood, but efforts are underway to identify medical treatment options.
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Affiliation(s)
- Deborah A Schwengel
- Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Nicholas M Dalesio
- Division of Pediatric Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracey L Stierer
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 N. Caroline Street, 6th Floor, Baltimore, MD 21287, USA
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11
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Baugh RF. Observation following Tonsillectomy May Be Inadequate Due to Silent Death. Otolaryngol Head Neck Surg 2014; 151:709-13. [DOI: 10.1177/0194599814545758] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The focus on the first 24 hours of care for respiratory events following tonsillectomy may be misplaced and a broader focus is warranted. Nocturnal hypoxemia, an elevated apnea-hypopnea index, or obstructive sleep apnea contributes to an increased sensitivity to narcotics and postoperative complications. Narcotic pain management depresses respiration through an increase in the frequency of central sleep apnea, decreased minute ventilation, increased hypercarbia pressure, and a decrease in the hypoxic ventilator response. Residual pain gives some margin of safety as it stimulates respiration. Children dying following tonsillectomy do so silently during sleep, often without arousing the attention of caregivers or nursing personnel in close proximity. Perioperative education of caregivers, use of the least morbid surgical technique, and the control of pain rather than its elimination are prudent steps in the management of tonsillectomy patients.
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Affiliation(s)
- Reginald F. Baugh
- Department of Surgery, Division of Otolaryngology, The University of Toledo Medical Center, Toledo, Ohio, USA
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Theilhaber M, Arachchi S, Armstrong DS, Davey MJ, Nixon GM. Routine post-operative intensive care is not necessary for children with obstructive sleep apnea at high risk after adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2014; 78:744-7. [PMID: 24594232 DOI: 10.1016/j.ijporl.2014.01.032] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 01/23/2014] [Accepted: 01/26/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Post-operative respiratory adverse events (AE) are frequent in children having adenotonsillectomy (AT) for obstructive sleep apnea (OSA). Many hospitals have a policy of routine admission to the intensive care unit (ICU) after surgery for children at highest risk. We aimed to determine the frequency and severity of post-operative AE in children admitted to ICU, to assess the appropriateness of this care plan. METHODS A retrospective chart review was carried out all children admitted to the pediatric intensive care unit after AT for OSA from January 2007 to December 2009. AE were classified as mild, including requirement for supplemental O2 or repositioning to improve airway or severe, including bag and mask ventilation, CPAP, re-intubation, placement of oropharyngeal airway or unplanned ICU admission for airway compromise. RESULTS 72 children were identified (21 female, median age 2.8 years). There were 29 AE in 26 patients (36%), including 23 (31.9%) who suffered a mild AE and 6 (8.3%) who had a severe AE. Age, sex, the presence of co-morbidity or the presence of severe OSA did not predict severe AE in this group. Median time to first AE was 165min. Four of the six severe AE occurred in the post-anesthetic care unit (PACU). There were 60 children who did not have an AE in PACU, of whom 59 did not have a severe AE in the post-operative period, giving a negative predictive value for no worse than a mild AE following an uncomplicated course in PACU of 98.3%. CONCLUSIONS Our data confirm high rates of AE after AT for high risk patients, however, only 8% suffered a severe AE truly necessitating care in ICU. This outcome was very unlikely if an AE did not occur in PACU. We therefore conclude that routine post-operative ICU care for high risk children may be avoided if prolonged monitoring in the PACU is possible, with admission to ICU reserved for high-risk children with an early AE.
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Affiliation(s)
- Marc Theilhaber
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Monash Medical Centre, Melbourne, Australia
| | - Sarah Arachchi
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Monash Medical Centre, Melbourne, Australia
| | - David S Armstrong
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Monash Medical Centre, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia
| | - Margot J Davey
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Monash Medical Centre, Melbourne, Australia; The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Australia
| | - Gillian M Nixon
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Monash Medical Centre, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia; The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Australia.
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Hack H. An audit of the use of an opiate sparing, multimodal analgesic regime in children with Sleep Disordered Breathing/Obstructive Sleep Apnoea undergoing adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2014; 78:119-23. [PMID: 24290004 DOI: 10.1016/j.ijporl.2013.10.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 10/25/2013] [Accepted: 10/29/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Children with Sleep Disordered Breathing/Obstructive Sleep Apnoea have an increased incidence of respiratory complications following adenotonsillectomy. This may be partly related to an increase in sensitivity to opiates. An audit of such cases undergoing adenotonsillectomy was performed with the following aims: METHODS All patients had Sleep Disordered Breathing/Obstructive Sleep Apnoea confirmed preoperatively by Overnight Oximetry Studies. Oximetry data was expressed as the lowest recorded saturation (SpO2 Low %) and number of significant desaturations (see text) per hour (ODI4%). Case notes and oximetry studies were scrutinized for relevant perioperative anaesthetic and analgesic data, risk factors and complications. RESULTS The overall incidence of major and minor respiratory complications was low (1.6% and 27% respectively). Children who suffered any complication were more likely to be younger (p=0.0078), have a lower SpO2 Low (p=0.004) and higher ODI4% (p=<0.0001). Multiple logistic regression showed ODI4% to be the best predictor of a potential respiratory complication (p=0.0032). An ODI4% of >8 may be the best cut off point in predicting complications (AUC=0.78, sensitivity=0.90) but it showed a poor specificity (0.57). Primary/secondary haemorrhage occurred in 0.4%/1.2% respectively and postoperative nausea and vomiting in 4.4%. CONCLUSIONS A low dose opiate-based, multi modal analgesic regime appears to be effective and safe in children with Sleep Disordered Breathing/Obstructive Sleep Apnoea undergoing adenotonsillectomy.
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Affiliation(s)
- Henrik Hack
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, UK.
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Brown KA. Evaluation of the Child with Sleep-Disordered Breathing Scheduled for Adenotonsillectomy. Sleep Med Clin 2013. [DOI: 10.1016/j.jsmc.2012.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gleich SJ, Olson MD, Sprung J, Weingarten TN, Schroeder DR, Warner DO, Flick RP. Perioperative outcomes of severely obese children undergoing tonsillectomy. Paediatr Anaesth 2012; 22:1171-8. [PMID: 22776351 PMCID: PMC3470734 DOI: 10.1111/j.1460-9592.2012.03905.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sleep-disordered breathing, a common condition in obese children, is a frequent indication for tonsillectomy. OBJECTIVE The purpose of this study was to examine the association between obesity and perioperative complications in children undergoing tonsillectomy. METHODS/MATERIALS A sample of 100 severely obese children (body mass index for age [BMIA], ≥ 98 th percentile) between ages 2 and 18 years who underwent tonsillectomy at Mayo Clinic Rochester was randomly selected. Each severely obese child was age (± 2 years) and sex matched to two normal weight children (BMIA between 25th and 75th percentiles) undergoing tonsillectomy during the study period, and their medical records were reviewed. RESULTS Severely obese children had a significantly higher incidence of comorbid conditions including respiratory disorders and severe systemic disorders or syndromes. Severely obese children had a higher frequency of perioperative airway complications (15.0% vs 2.0%). From posthoc analyses, severe obesity remained a significant risk factor for perioperative adverse events after adjusting for the presence of severe systemic disorders or syndromes (OR 8.8; 95% CI 2.8-27.5, P < 0.001) and also after adjusting for preoperative respiratory disorders (OR 7.7; 95% CI 2.5-24.3, P < 0.001). When children with planned admissions were excluded from the analysis, severe obesity was associated with an increased rate of unplanned hospital admission (OR 3.80, 95% CI 1.8-7.9, P < 0.001). CONCLUSIONS Severe obesity in children undergoing tonsillectomy is independently associated with an increased risk of perioperative complications. It appears that both severe obesity and systemic comorbid condition contribute to higher proportions of inpatient tonsillectomies performed in our institution.
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Affiliation(s)
| | - Michael D. Olson
- Mayo Medical School, College of Medicine, Mayo Clinic, Rochester MN
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic, Rochester MN
,Corresponding Author: Juraj Sprung, M.D., Ph.D., Department of Anesthesiology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, Phone: (507) 255-3298, Fax: (507) 255-6463,
| | | | - Darrell R. Schroeder
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic, Rochester MN
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Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Ward SD, Sheldon SH, Shiffman RN, Lehmann C, Spruyt K. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012; 130:e714-55. [PMID: 22926176 DOI: 10.1542/peds.2012-1672] [Citation(s) in RCA: 968] [Impact Index Per Article: 80.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS). METHODS The literature from 1999 through 2011 was evaluated. RESULTS AND CONCLUSIONS A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.
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Abstract
Obstructive sleep apnea (OSA) can affect all ages from infants to adults. The clinical pathology is initially age-dependent and symptoms first become comparable to those in adults during adolescence. Significant indications for OSA during childhood are craniofacial dysmorphia, failure to thrive, susceptibility to infections or delayed development of speech. Prior to puberty children can become conspicuous due to agitation, attention deficits, poor school performance or secondary enuresis. Crucial for anesthesia is a presumptive diagnosis in order to consider OSA for the forthcoming strategy. Safety aspects in the treatment of OSA children are especially related to the perioperative securing of the airway and a sufficiently long monitoring of respiratory functions.
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Abstract
Adenotonsillectomy is the mainstay of treatment for pediatric obstructive sleep apnea syndrome (OSAS). However, there is evidence that the child with severe OSAS is at increased risk of respiratory compromise. The most difficult risk factor to assess is the severity of OSAS, and these difficulties are reviewed.
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Affiliation(s)
- Karen A Brown
- Department of Pediatric Anesthesia, McGill University Health Centre/Montreal Children's Hospital, Montreal, QC, Canada.
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Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, Kuhar S, Mitchell RB, Seidman MD, Sheldon SH, Jones S, Robertson P. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 145:S1-15. [PMID: 21676944 DOI: 10.1177/0194599811409837] [Citation(s) in RCA: 302] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This guideline provides otolaryngologists with evidence-based recommendations for using polysomnography in assessing children, aged 2 to 18 years, with sleep-disordered breathing and are candidates for tonsillectomy, with or without adenoidectomy. Polysomnography is the electrographic recording of simultaneous physiologic variables during sleep and is currently considered the gold standard for objectively assessing sleep disorders. PURPOSE There is no current consensus or guideline on when children 2 to 18 years of age, who are candidates for tonsillectomy, are recommended to have polysomnography. The primary purpose of this guideline is to improve referral patterns for polysomnography among these patients. In creating this guideline, the American Academy of Otolaryngology--Head and Neck Surgery Foundation selected a panel representing the fields of anesthesiology, pulmonology medicine, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. RESULTS The committee made the following recommendations: (1) before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (2) The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in statement 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing. (3) Clinicians should communicate polysomnography results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing. (4) Clinicians should admit children with obstructive sleep apnea documented on polysomnography for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both). (5) In children for whom polysomnography is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based polysomnography, when available.
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Affiliation(s)
- Peter S Roland
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
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Kelz RR, Tran TT, Hosokawa P, Henderson W, Paulson EC, Spitz F, Hamilton BH, Hall BL. Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. J Am Coll Surg 2009; 209:434-445.e2. [PMID: 19801316 DOI: 10.1016/j.jamcollsurg.2009.05.022] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 05/11/2009] [Accepted: 05/12/2009] [Indexed: 12/20/2022]
Abstract
BACKGROUND Surgical care is delivered around the clock. Elective cases within the Veterans Affairs health system starting after 4 pm appear to have an elevated risk of morbidity, but not mortality, compared with earlier cases. The relationship between operation start time and patient outcomes is not described in private-sector patients or for emergency cases. STUDY DESIGN We performed a retrospective cohort study of 56,920 general and vascular surgical procedures performed from October 2001 through September 2004, and entered into the National Surgical Quality Improvement Program database. Operation start time was the independent variable of interest. Random effects, hierarchical logistic regression models adjusted for patient, operative, and facility characteristics. Two independent models determined associations between start time and morbidity or mortality. Subset analysis was performed for emergency and nonemergency cases. RESULTS After adjustment for patient and procedure characteristics, mortality had a moderately strong association with start time, but only for nonemergency cases starting 9:30 pm to 7:30 am (odds ratio = 1.752; p = 0.028; reference 7:30 am to 9:30 am). As for morbidity, after adjustment, operations starting 9:30 am to 1:30 pm and 5:30 pm to 9:30 pm were associated with a weakly elevated risk of morbidity, but those starting 9:30 pm to 7:30 am demonstrated a strong effect on morbidity (odds ratio = 1.32; p < 0.0001). Subgroup analysis showed this effect was largely a result of elevated risk of morbidity in emergency cases from this overnight time period (odds ratio = 1.48; p = 0.001). CONCLUSIONS Surgical start times are associated with risk-adjusted patient outcomes. In terms of facility operations management and resource allocation, consideration should be given to the capacity to accommodate cases with differences in risk during different time periods.
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Affiliation(s)
- Rachel R Kelz
- Department of Surgery, Philadelphia VA Medical Center, Philadelphia, PA, USA.
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Schwengel DA, Sterni LM, Tunkel DE, Heitmiller ES. Perioperative management of children with obstructive sleep apnea. Anesth Analg 2009; 109:60-75. [PMID: 19535696 DOI: 10.1213/ane.0b013e3181a19e21] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Obstructive sleep apnea syndrome (OSA) affects 1%-3% of children. Children with OSA can present for all types of surgical and diagnostic procedures requiring anesthesia, with adenotonsillectomy being the most common surgical treatment for OSA in the pediatric age group. Thus, it is imperative that the anesthesiologist be familiar with the potential anesthetic complications and immediate postoperative problems associated with OSA. The significant implications that the presence of OSA imposes on perioperative care have been recognized by national medical professional societies. The American Academy of Pediatrics published a clinical practice guideline for pediatric OSA in 2002, and cited an increased risk of anesthetic complications, though specific anesthetic issues were not addressed. In 2006, the American Society of Anesthesiologists published a practice guideline for perioperative management of patients with OSA that noted the pediatric-related risk factor of obesity, and the increased perioperative risk associated with adenotonsillectomy in children younger than 3 yr. However, management of OSA in children younger than 1 yr-of-age was excluded from the guideline, as were other issues related specifically to the pediatric patient. Hence, many questions remain regarding the perioperative care of the child with OSA. In this review, we examine the literature on pediatric OSA, discuss its pathophysiology, current treatment options, and recognized approaches to perioperative management of these young and potentially high-risk patients.
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Affiliation(s)
- Deborah A Schwengel
- Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, Department of Anesthesiology/Critical Care Medicine, 600 North Wolfe St., Blalock 1412, Baltimore, MD 21287-8711, USA.
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Key issues and barriers to obstetrical anesthesia care in Ontario community hospitals with fewer than 2,000 deliveries annually. Can J Anaesth 2009; 56:667-77. [PMID: 19533265 DOI: 10.1007/s12630-009-9128-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 05/22/2009] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Lack of the availability of anesthesia services may be a factor in the closure of maternity services in rural Canada, limiting the capacity for Cesarean delivery and intensifying the urbanization of maternity care. Unlike other professions involved in maternal newborn care, health services research in obstetrical anesthesia is virtually non-existent. This study explored barriers physicians encountered in providing obstetrical anesthesia care in Ontario community hospitals experiencing low volumes (fewer than 2,000) deliveries per annum (PA). Solutions proposed by a mixed focus group of academic and community hospital leaders were also described. METHODS Following Research Ethics Board approval, the authors performed a secondary analysis of qualitative data from 18 anesthesiologists and family practitioner (FP/GP) anesthetists who had participated in a larger provincial study that was also conducted by the authors. Participants were leaders from community hospitals with fewer than 2000 deliveries PA and university-based teaching programs from across Ontario. Fourteen community physicians participated in focus groups that explored key issues and barriers to care and their potential solutions. A final group of eight academic and community physician key informants further explored solutions. FINDINGS Three themes emerged: Obstetrical Anesthesia in the "Periphery", "Key Issues and Barriers to Obstetrical Anesthesia Care", and "A Multi-faceted but Context-Specific Solution is Required." The physicians identified barriers within the greater context of those encountered during the provision of anesthesia services in the periphery, including lack of time, need for continuing medical education (CME), need for hospital infrastructure support to develop and implement best practice protocols, and need for resources and anesthesia mentorship supports from the system. Difficulties were greatest for FP/GP anesthetists in rural communities who described lack of locums, need for relevant CME, and worsening physician shortages threatening provision of services in some rural hospitals. Family practitioner anesthetist multi-taskers were described as the best solution to the provider shortage in rural communities. Participants described the need for increased numbers of FP/GP anesthetists and the development of formal funded networks for knowledge transfer between academic and community hospitals as a mechanism to provide supports. CONCLUSIONS Physicians in community hospitals face significant barriers in the provision of obstetrical anesthesia care. These are greatest among FP/GP anesthetists and in rural hospitals where physician shortages and lack of supports threaten provision of services in some hospitals. Local context-specific and systems-level solutions are required.
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Abstract
Adenotonsillectomy (T&A) is a common surgical procedure. Its frequency is highest in the paediatric age range and its most common current indication is obstructive sleep apnoea (OSA). Sleep studies are used to document the presence and severity of OSA. This review will focus on indications for and complications of T&A in the context of the age range and setting where this surgery is undertaken for OSA in children.
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Affiliation(s)
- Karen A Waters
- Respiratory Support Service and Sleep Unit, The Children's Hospital at Westmead and Discipline of Paediatrics, Department of Medicine, The University of Sydney, Australia.
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Allford M, Guruswamy V. A national survey of the anesthetic management of tonsillectomy surgery in children. Paediatr Anaesth 2009; 19:145-52. [PMID: 19143956 DOI: 10.1111/j.1460-9592.2008.02860.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tonsillectomy in children is a common procedure; however, there appears to be a significant degree of variability in anesthetic management. Thus far, there has been no large national survey looking at the perioperative care of these children. OBJECTIVES We conducted a national survey with the aim of determining what represents common practice in the perioperative management of children undergoing tonsillectomy surgery. We compared the respondents' management against evidence-based practice. METHODS The survey took the form of a questionnaire, which was sent to members of The Association of Paediatric Anaesthetists (APAGBI) and to Royal College tutors. The questionnaire was sent in paper format to the College Tutors and in digital format to APAGBI members. Emphasis was placed upon preoperative preparation, induction technique, airway management, analgesia, postoperative nausea and vomiting strategy, fluid management and emergence from anesthesia. RESULTS Responses were obtained from 173 individuals representing a broad cross-section of anesthetists from teaching and district general hospitals. Findings are as follows: the application of topical anesthetic cream is commonplace (93%), with Ametop being the primary preparation used; the intravenous route was preferred to induce anesthesia; most practitioners intubate the trachea to maintain the airway during anesthesia (79%); a muscle relaxant was employed to assist intubation of the trachea in 47% of respondents and the routine use of suxamethonium was reported to be uncommon (9%); the administration of prophylactic ondansetron and dexamethasone was reported by 79% and 70% of respondents respectively; and nonsteroidal anti-inflammatory drugs (NSAIDs) are used by 77% of individuals either pre-emptively or during the intraoperative period. CONCLUSIONS Whilst there is individual variability in the management of these cases, the majority of anesthetists prefer the intravenous route for induction of anesthesia, after application of topical anesthetic cream. It is routine practice to intubate the trachea, administer paracetamol, NSAIDs, strong opiates and antiemetics.
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Affiliation(s)
- Mark Allford
- Department of Anaesthesia, Jubilee Wing, Leeds General Infirmary, Leeds, UK.
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Praud JP, Dorion D. Obstructive sleep disordered breathing in children: beyond adenotonsillectomy. Pediatr Pulmonol 2008; 43:837-43. [PMID: 18680183 DOI: 10.1002/ppul.20888] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Traditionally, adenotonsillectomy (AT) has long been the treatment of choice for obstructive sleep disordered breathing (SDB) in children. AT is usually considered a safe procedure, which cures 80% of children with SDB. Accumulated data have however challenged this overly simplistic view. Indeed, AT is invariably associated with significant morbidity, post-operative pain, and a mortality rate which, though low, cannot be ignored. In addition, aside from a recurrence of SDB at adolescence in an unknown percentage of cases, some recent results suggest that complete SDB cure is not achieved in as much as 75% of cases after AT. Interestingly, several treatment options have been recently proposed for replacing or complementing AT. Continuous positive airway pressure (CPAP) is now suggested in children with remaining SDB after AT; however, compliance and suitability of equipment remain important hurdles, especially in small children and infants. Anti-inflammatory treatments, including nasal glucocorticoids and/or the anti-leukotriene montelukast, appear to hold great promise. Finally, orthodontic treatments are an appealing option, with recent results in children suggesting that it is possible to improve or perhaps even cure SDB in a durable manner by enlarging the nasal passages and/or the oropharyngeal airspace. In conclusion, while we are currently in the midst of an exciting time with several new treatments being developed for childhood SDB, randomized controlled trials are urgently needed to delineate their indications. In the meantime, it appears that systematic detection of orthodontic anomalies and better collaboration with maxillofacial specialists, including orthodontists and/or dentists, is needed for deciding the best treatment options for childhood SDB.
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Affiliation(s)
- Jean-Paul Praud
- Respiratory Medicine Division, Department of Pediatrics, Université de Sherbrooke, Québec, Canada.
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Brouillette RT, Constantin E, McGregor CD. Case 1: Sounds like trouble. Paediatr Child Health 2007; 12:313-6. [DOI: 10.1093/pch/12.4.313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2007] [Indexed: 12/25/2022] Open
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Brown KA. 203 Anesthetic and perioperative management. Sleep Med 2006. [DOI: 10.1016/j.sleep.2006.07.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hullett BJ, Chambers NA, Pascoe EM, Johnson C. Tramadol vs morphine during adenotonsillectomy for obstructive sleep apnea in children. Paediatr Anaesth 2006; 16:648-53. [PMID: 16719881 DOI: 10.1111/j.1460-9592.2005.01827.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal analgesia for children undergoing adenotonsillectomy for obstructive sleep apnea (OSA) is controversial. Tramadol may represent a superior choice over morphine in this group, with a potential to cause less postoperative sedation and respiratory depression. Optimal perioperative analgesia may allow expensive and time-consuming preoperative work-up and postoperative monitoring to be rationalized. METHODS Sixty-six children were randomized to receive either perioperative tramadol or morphine in this double blinded, prospective, controlled trial. Postoperative sedation, pain, respiratory events, and vomiting were then compared between groups. RESULTS There was no significant difference between the two groups in sedation scores 1 h after arrival in recovery (P = 0.24) or at any other time up to 6 h postoperation. There was also no evidence of a difference between the groups in pain scores up to 6 h postoperation. There were fewer episodes of postoperative desaturation (<94%) in the tramadol group up to 3 h postoperation, with 26% fewer episodes in the tramadol group during the second hour postoperation (P = 0.02). Overall, there was a trend toward fewer desaturation episodes in the tramadol group. CONCLUSIONS Tramadol may be a suitable drug for children undergoing adenotonsillectomy for OSA. Further work is required to investigate this.
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Affiliation(s)
- Bruce J Hullett
- Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, WA, Australia.
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Abstract
Despite increasing recognition of childhood obstructive sleep apnea syndrome (OSAS) as a significant public health problem, treatment of the condition remains inconsistent. Some children are screened using polysomnography and treated only when objective respiratory disturbances are identified. Many others receive adenotonsillectomy based only on signs and symptoms of upper airway obstruction without ever having a formal sleep study. Outcome-based data regarding the effectiveness of adenotonsillectomy, continuous positive airway pressure, and other treatments for childhood OSAS remain extremely limited. In this article, the major therapeutic options for treatment of childhood OSAS are reviewed. Adenotonsillectomy remains the most frequently used treatment for uncomplicated OSAS in children, but residual airway obstruction persists in a notable minority of patients. Nasal continuous positive airway pressure is used for children who are not good surgical candidates or who have failed previous surgical treatment, but is sometimes not tolerated by young children or their parents. Various alternative treatments are used on an individualized basis for children who cannot use the two first-line therapies for sleep apnea.
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Affiliation(s)
- Timothy F Hoban
- Department of Pediatrics, L3227, Women's Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Nixon GM, Kermack AS, McGregor CD, Davis GM, Manoukian JJ, Brown KA, Brouillette RT. Sleep and breathing on the first night after adenotonsillectomy for obstructive sleep apnea. Pediatr Pulmonol 2005; 39:332-8. [PMID: 15704184 DOI: 10.1002/ppul.20195] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Adenotonsillectomy (T&A) has established effectiveness for the treatment of obstructive sleep apnea (OSA). However, more than 20% of children with OSA have respiratory compromise requiring medical intervention in the postoperative period. The reasons for this complication are not well-defined. We aimed to compare the nature and severity of sleep-disordered breathing in children with mild and severe OSA on the first night following adenotonsillectomy. Ten children were classified into groups of mild and severe OSA, based on preoperative testing. On the first night after T&A, they underwent polysomnography, including electroencephalograph, submental electromyography, bilateral electro-oculograms, monitoring of respiratory movements, heart rate, ECG, and oxygen saturation. Sleep-disordered breathing was assessed by the apnea-hypopnea index, the SaO(2) nadir, and the desaturation index, including dips in saturation below 90% (DI(90)). Sleep quality was assessed by sleep efficiency, time spent in each sleep state, and respiratory arousal index. Obstructive events occurred postoperatively in all children, but were more frequent in those with severe OSA preoperatively: the median (interquartile range) mixed/obstructive apnea/hypopnea indicies were 6.9 (2.2-9.8) events/hr and 21.5 (15.1-112.1) events/hr for the mild OSA group and the severe OSA group, respectively (P = 0.009). Obstructive events were the major cause of desaturation during sleep postoperatively. Sleep quality was severely disrupted in both groups, with reductions in both slow-wave sleep and rapid eye movement sleep. In conclusion, despite removal of obstructing lymphoid tissue, upper airway obstruction occurred on the first postoperative night in children with OSA. This study is the first to demonstrate the mechanism of respiratory compromise after adenotonsillectomy, a common postoperative complication in children with severe OSA.
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Affiliation(s)
- G M Nixon
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.
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Coté CJ, Sheldon SH. Obstructive sleep apnea and tonsillectomy: do we have a new indication for extended postoperative observation? Can J Anaesth 2004; 51:6-12. [PMID: 14709453 DOI: 10.1007/bf03018539] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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