1
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Benyo S, Moroco AE, Saadi RA, Patel VA, King TS, Wilson MN. Postoperative Outcomes in Pediatric Septoplasty. Ann Otol Rhinol Laryngol 2022:34894221129677. [PMID: 36226335 DOI: 10.1177/00034894221129677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Identify risk factors and perioperative morbidity for pediatric patients undergoing septoplasty. METHODS The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was retrospectively queried to identify patients who underwent septoplasty (CPT 30520) for a diagnosis of deviated nasal septum (ICD J34.2) from 2018 to 2019. Outcomes analyzed include patient demographics, medical comorbidities, surgical setting, operative characteristics, length of stay, and postoperative outcomes. RESULTS A total of 729 children were identified. Median age at time of surgery was 15.8 years, with most patients (82.8%) >12 years of age; no significant association was identified between age at time of surgery and adverse surgical outcomes. Overall, postoperative complications were uncommon (0.6%), including readmission (0.4%), septic shock (0.1%), and surgical site infection (0.1%). A history of asthma was found to be a significant risk factor for postoperative complications (P = .035) as well as BMI (P = .028). CONCLUSION The 30-day postoperative complications following pediatric septoplasty in children reported in the NSQIP-P database are infrequent. Special considerations regarding young age, complex sinonasal anatomy, and surgical technique remain important features in considering corrective surgery for the pediatric nose and certainly warrant further investigation in subsequent studies.
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Affiliation(s)
- Sarah Benyo
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Annie E Moroco
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert A Saadi
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Vijay A Patel
- Department of Surgery, Division of Otolaryngology - Head and Neck Surgery, University of California San Diego, La Jolla, CA, USA.,Division of Pediatric Otolaryngology, Rady Children's Hospital - San Diego, San Diego, CA, USA
| | - Tonya S King
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Meghan N Wilson
- Department of Otolaryngology - Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
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2
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Campisi ES, Reyna ME, Brydges M, Dubeau A, Moraes TJ, Campisi P, Subbarao P. Adenotonsillectomy, bronchoscopy and bronchoalveolar lavage in the management of preschool children with severe asthma: pilot study. Eur Arch Otorhinolaryngol 2021; 279:319-326. [PMID: 34542655 DOI: 10.1007/s00405-021-07084-x] [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: 07/05/2021] [Accepted: 09/10/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE This is a pilot study that describes the feasibility and clinical course of a cohort of preschool children with severe asthma undergoing a combined adenotonillectomy (TA), bronchoscopy (B), and bronchoalveolar lavage (BAL) procedure. METHODS A retrospective cohort study of preschool patients with severe asthma who underwent a combined TA-B-BAL procedure between 2012 and 2019. Subjects were treated at a tertiary care asthma clinic and had a diagnosis of preschool asthma according to the Canadian Thoracic Society Guidelines. Data on demographics, clinical characteristics, medication use, virology and microbiology from bronchoalveolar lavage, and asthma control questionnaires were collected. Variables were analyzed using paired t test. RESULTS Eighteen preschool subjects (mean age 3.19 ± 1.13 years) with severe asthma were identified through the asthma clinic. Patients treated with standard asthma care and a combined TA-B-BAL procedure experienced a decrease in the number of oral steroid courses (p = 0.017), emergency department visits (p = 0.03) and wheezing exacerbations (p = 0.026) following the procedure. Ten patients experienced clinically meaningful improvements in TRACK scores after the procedure (p < 0.001). CONCLUSION This pilot study provides early evidence that a combined TA-B-BAL procedure is feasible in preschool children with severe asthma and that the procedure may reduce asthma medication use and hospital visits.
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Affiliation(s)
- Emma S Campisi
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Myrtha E Reyna
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - May Brydges
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - Aimee Dubeau
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - Theo J Moraes
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - Paolo Campisi
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Padmaja Subbarao
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada.,Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, 27 King's College Circle, Toronto, Canada
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3
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Mattioni J, Azari S, Hoover T, Weaver D, Chennupati SK. A Cross-Sectional Evaluation of Outcomes of Pediatric Thyroglossal Duct Cyst Excision. ORL J Otorhinolaryngol Relat Spec 2021; 84:114-121. [PMID: 34325433 DOI: 10.1159/000516592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Thyroglossal duct cysts (TGDCs) are the most common form of congenital neck cysts. They may become infected causing dysphagia or respiratory distress. Accordingly, the treatment is always surgical removal. OBJECTIVES The objectives of this article were to examine complications following TGDC excision by surgical specialty, demographics, and comorbid conditions. METHODS A retrospective review of the National Surgical Quality Improvement Program database was performed. Pediatric cases from January 1, 2014 to November 1, 2015 with a current procedure terminology code of 60,280 (excision of TGDC or sinus) were included. Statistical analysis was performed to assess associations between complications and surgical specialty, demographics, and comorbidities. RESULTS Of the 867 cases that met inclusion criteria, the median age was 4 years. There were 448 males (52.3%) and 408 females (47.7%). Thirty-six patients (4.2%) experienced at least one 30-day complication. The most predominant complications were reoperation (19 patients, 2.2%), readmission (18 patients, 2.1%), and surgical site infection (16 patients, 1.9%). There was no statistically significant difference between complications and surgical specialty. In those experiencing a complication, there was a statistically significant difference between males (86.1%) and females (13.9%). Of patients with at least one comorbidity, 36.67% had a complication, while 17.22% did not have a complication. There was also a statistically significant difference in the percentage of patients with a past medical history of asthma between those with at least one complication (16.67%) compared to those without any complications (4.76%). CONCLUSIONS excision is a generally safe procedure across surgical specialties. There is a higher complication rate in males compared to females as well as those with a history of at least one medical comorbidity and those with asthma. The most common 30-day complications are reoperation, readmission, and surgical site infection.
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Affiliation(s)
- Jillian Mattioni
- Department of Otolaryngology, Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Sarah Azari
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Travis Hoover
- Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Daniel Weaver
- College of Health, Lehigh University, Bethlehem, Pennsylvania, USA
| | - Sri Kiran Chennupati
- Pediatric Otolaryngology, Lehigh Valley Health Children's Hospital, Allentown, Pennsylvania, USA
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4
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Winch PD, Mpody C, Murray-Torres TM, Rudolph S, Tobias JD, Nafiu OO. Unplanned Postoperative Reintubation in Children with Bronchial Asthma. J Pediatr Intensive Care 2021; 11:287-293. [DOI: 10.1055/s-0041-1724097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022] Open
Abstract
AbstractUnplanned postoperative reintubation is a serious complication that may increase postsurgical hospital length of stay and mortality. Although asthma is a risk factor for perioperative adverse respiratory events, its association with unplanned postoperative reintubation in children has not been comprehensively examined. Our aim was to determine the association between a preoperative comorbid asthma diagnosis and the incidence of unplanned postoperative reintubation in children. This was a retrospective cohort study comprising of 194,470 children who underwent inpatient surgery at institutions participating in the National Surgical Quality Improvement Program–Pediatric. The primary outcome was the association of preoperative asthma diagnosis with early, unplanned postoperative reintubation (within the first 72 hours following surgery). We also evaluated the association between bronchial asthma and prolonged hospital length of stay (longer than the 75th percentile for the cohort). The incidence of unplanned postoperative reintubation in the study cohort was 0.5% in patients with a history of asthma compared with 0.2% in patients without the diagnosis (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.71–2.89). This association remained significant after controlling for several clinical characteristics (OR: 1.54, 95% CI: 1.17–2.20). Additionally, asthmatic children were more likely to require a hospital length of stay longer than the 75th percentile for the study cohort (adjusted OR: 1.05, 95% CI: 1.01–1.10). Children with preoperative comorbid asthma diagnosis have an increased incidence of early, unplanned postoperative reintubation and prolonged postoperative hospitalization following inpatient surgery. By identifying these patients as having higher perioperative risks, it may be possible to institute strategies to improve their outcomes.
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Affiliation(s)
- Peter D. Winch
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Teresa M. Murray-Torres
- Department of Anesthesiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Shannon Rudolph
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Medical Student Research Program, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States
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5
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Abstract
Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.
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Affiliation(s)
- Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, A330, Houston, TX 77030, USA.
| | - Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, A330, Houston, TX 77030, USA
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6
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Mahant S, Richardson T, Keren R, Srivastava R, Meier J. Variation in tonsillectomy cost and revisit rates: analysis of administrative and billing data from US children's hospitals. BMJ Qual Saf 2020; 30:bmjqs-2019-010730. [PMID: 32606211 DOI: 10.1136/bmjqs-2019-010730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 04/28/2020] [Accepted: 05/25/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tonsillectomy is one of the most common and cumulatively expensive surgical procedures in children. We determined if substantial variation in resource use, as measured by standardised costs, exists across hospitals for performing tonsillectomy and if higher resource use is associated with better quality of care, as measured by revisits to hospital. METHODS We conducted a retrospective analysis of children undergoing routine outpatient tonsillectomy between 2011 to 2017 across US children's hospitals using an administrative and billing data source. The primary outcome measures were the hospital tonsillectomy standardised cost and the 30-day revisit rate to hospital. We analysed the interhospital variation in standardised cost by determining the number of outlier hospitals in standardised cost and the intraclass correlation coefficient. RESULTS 131 814 children (median age 6 years, IQR: 4,9; female sex 52.5%) underwent tonsillectomy for airway obstruction (62.9%) and infection (23.9%) across 28 hospitals. The median adjusted hospital standardised cost for tonsillectomy was $2392 (IQR: $1827, $2793; range: $1166 to $4222). There was substantial interhospital variation in costs as 11 (40%) hospitals were cost outliers, and the intraclass correlation coefficient was 0.62, suggesting that 62% of the variation in cost was attributable to variation between hospitals. The median hospital revisit rate was 9.5% (IQR: 7.8, 12.1) and higher hospital costs did not correlate with lower revisit rates (rs =0.03, 95% CI -0.36 to 0.41; p=0.87). CONCLUSIONS There is substantial variation in hospital resource use and standardised costs for routine outpatient tonsillectomy across US children's hospitals. Higher resource use is not associated with lower revisit rates. Further study is needed to understand the practices of lower resource use hospitals who deliver high quality of care.
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Affiliation(s)
- Sanjay Mahant
- Department of Pediatrics and Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Troy Richardson
- Research and Statistics, Children's Hospital Association, Lexena, Kansas, USA
| | - Ron Keren
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rajendu Srivastava
- Department of Pediatrics, Primary Children's Hospital, Salt Lake City, Utah, USA
- Healthcare Delivery Institute, Intermountain Health Inc, Salt Lake City, Utah, United States
| | - Jeremy Meier
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, United States
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7
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Abstract
Post-adenotonsillectomy pulmonary edema (pATPE) is a life-threatening condition that necessitates immediate clinical intervention. The early diagnosis and detection of the signs of this condition is vital to its treatment and patient outcome. The purpose of this review article is to present epidemiological data on the prevalence of pATPE, and address the mechanisms of development, types, etiology, pathophysiology, and management of pATPE. In order to minimize postoperative intensive care unit admission rates of pATPE, utilization of preoperative clinical assessment, operative/postoperative monitoring tools, and procedural precautions are discussed.
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Affiliation(s)
- Elaf Ahmed
- Department of Otorhinolaryngology, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia. E-mail.
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8
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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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9
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Kozanhan B, Iyisoy MS. Red cell distribution width as a novel predictor of postoperative respiratory adverse events after adenotonsillectomy. Paediatr Anaesth 2017; 27:609-615. [PMID: 28345782 DOI: 10.1111/pan.13138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Respiratory adverse events are commonly observed after adenotonsillectomy in children with sleep-disordered breathing. Preoperative prediction of these events enhances quality of care and resource management in facilities while encouraging precautions against them. Red cell distribution width, a measure of erythrocyte size variability, has recently been linked to adverse outcomes in a variety of disorders. Red cell distribution width has also been found to be associated with severity of obstructive sleep apnea in adults due to hypoxia-mediated inflammation. AIM The objective of this study was to evaluate whether elevated red cell distribution width is associated with postoperative respiratory adverse events in children with symptoms of sleep-disordered breathing. METHODS A prospective, observational, assessor-blinded study was conducted with consecutive children undergoing elective adenotonsillectomy for treatment of sleep-disordered breathing. Under general anesthesia, adenoidectomy was performed by curettage, and tonsillectomy was carried out by dissection. The primary outcome was the occurrence of an adverse event during emergence or in the postanesthesia care unit (PACU). RESULTS Among 287 patients, with mean ± sd age 7.49 ± 3.21, the frequency of respiratory complications during emergence was 62 (22.30%) and in PACU was 56 (20.14%). Mean ± sd red cell distribution width was 14.36 ± 1.06 in patients with complications and higher than that in those without complications 13.53 ± 0.59. Red cell distribution width had an adjusted odds ratio 7.28 (95% CI: 4.30-13.28) and area under the curve value 0.74 (95% CI: 0.67-0.81) to predict postoperative complications. A cutoff value for red cell distribution width was found to be 14.7. CONCLUSION Our study showed that preoperative elevated red cell distribution width is associated with an increased risk of respiratory adverse events in children undergoing adenotonsillectomy for sleep-disordered breathing.
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Affiliation(s)
- Betul Kozanhan
- Department of Anesthesiology and Reanimation, Education and Research Hospital, Konya, Turkey
| | - Mehmet S Iyisoy
- Department of Medical Education and Informatics, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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10
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Lin CS, Chang CC, Yeh CC, Chung CL, Chen TL, Liao CC. Postoperative Adverse Outcomes in Patients With Asthma: A Nationwide Population-based Cohort Study. Medicine (Baltimore) 2016; 95:e2548. [PMID: 26817903 PMCID: PMC4998277 DOI: 10.1097/md.0000000000002548] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Outcome after surgery in patients with asthma remains unknown. The purpose of this study is to investigate postoperative major complications and mortality in surgical patients with asthma.Using reimbursement claims from the Taiwan National Health Insurance Research Database, the authors identified 24,109 surgical patients with preoperative asthma and 24,109 nonasthma patients undergoing major surgeries using matching procedure with propensity score by sociodemographics, coexisting medical conditions, and surgical characteristics. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day postoperative complications and mortality associated with asthma were analyzed in the multivariate logistic regressions.Asthma increased postoperative pneumonia (OR 1.48; 95% CI 1.34-1.64), septicemia (OR 1.11; 95% CI 1.02-1.21), and urinary tract infection (OR 1.17; 95% CI 1.09-1.26). Preoperative emergency care for asthma was significantly associated with postoperative 30-day in-hospital mortality, with an OR of 1.84 (95% CI 1.11-3.04). Preoperative emergency service, hospitalizations, admission to intensive care unit, and systemic use of corticosteroids for asthma were also associated with higher postoperative complication rates for asthmatic patients.Postoperative complications and mortality were significantly increased in asthmatic patients. We suggest urgent efforts to revise protocols for asthma patients' perioperative care.
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Affiliation(s)
- Chao-Shun Lin
- From the Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan (CSL, CCC, TLC, CCL); Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan (CSL, CCC, TLC, CCL); Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan (CSL, CCC, TLC, CCL); Department of Surgery, China Medical University Hospital, Taichung, Taiwan (CCY); Department of Surgery, University of Illinois, Chicago, USA (CCY); Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan (CLC); School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan (CCL)
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11
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Mahant S, Hall M, Ishman SL, Morse R, Mittal V, Mussman GM, Gold J, Montalbano A, Srivastava R, Wilson KM, Shah SS. Association of National Guidelines With Tonsillectomy Perioperative Care and Outcomes. Pediatrics 2015; 136:53-60. [PMID: 26101361 DOI: 10.1542/peds.2015-0127] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate the association of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines with perioperative care processes and outcomes in children undergoing tonsillectomy. METHODS We conducted a retrospective cohort study of otherwise healthy children undergoing tonsillectomy between January 2009 and January 2013 at 29 US children's hospitals participating in the Pediatric Health Information System. We measured evidence-based processes suggested by the guidelines (perioperative dexamethasone and no antibiotic use) and outcomes (30-day tonsillectomy complication-related revisits). We analyzed rates aggregated over the preguideline and postguideline periods and then by month over time by using interrupted time series. RESULTS Of 111,813 children who underwent tonsillectomy, 54,043 and 57,770 did so in the preguideline and postguideline periods, respectively. Dexamethasone use increased from 74.6% to 77.4% (P < .001) in the preguideline to postguideline period, as did its rate of change in use (percentage change per month, -0.02% to 0.29%; P < .001). Antibiotic use decreased from 34.7% to 21.8% (P < .001), as did its rate of change in use (percentage change per month, -0.17% to -0.56%; P < .001). Revisits for bleeding remained stable; however, total revisits to the hospital for tonsillectomy complications increased from 8.2% to 9.0% (P < .001) because of an increase in revisits for pain. Hospital-level results were similar. CONCLUSIONS The guidelines were associated with some improvement in evidence-based perioperative care processes but no improvement in outcomes. Dexamethasone use increased slightly, and antibiotic use decreased substantially. Revisits for tonsillectomy-related complications increased modestly over time because of revisits for pain.
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Affiliation(s)
- Sanjay Mahant
- Division of Pediatric Medicine, Pediatric Outcomes Research Team (PORT), Department of Pediatrics, Institute of Health Policy, Management and Evaluation, University of Toronto, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada;
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Stacey L Ishman
- Division of Otolaryngology, Head & Neck Surgery, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, and Department of Otolaryngology, Head & Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rustin Morse
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vineeta Mittal
- Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Jessica Gold
- New York-Presbyterian Morgan Stanley Children's Hospital and Columbia University Medical Center, New York, New York
| | - Amanda Montalbano
- Children's Mercy Hospitals and Clinics and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Rajendu Srivastava
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah Health Sciences Center, Institute for Healthcare Delivery Research, Intermountain Healthcare Inc., Salt Lake City, Utah; and
| | - Karen M Wilson
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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12
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Martins RO, Castello-Branco N, Barros JLD, Weber SAT. Risk factors for respiratory complications after adenotonsillectomy in children with obstructive sleep apnea. ACTA ACUST UNITED AC 2015; 41:238-45. [PMID: 25909156 PMCID: PMC4541759 DOI: 10.1590/s1806-37132015000004415] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 02/03/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE: To identify risk factors for respiratory complications after adenotonsillectomy in children ≤ 12 years of age with obstructive sleep apnea who were referred to the pediatric ICU (PICU). METHODS: A cross-sectional historical cohort study analyzing 53 children after adenotonsillectomy who met predetermined criteria for PICU referral in a tertiary level teaching hospital. The Student's t-test, Mann-Whitney test, and chi-square test were used to identify risk factors. RESULTS: Of the 805 children undergoing adenotonsillectomy between January of 2006 and December of 2012 in the teaching hospital, 53 were referred to the PICU. Twenty-one children (2.6% of all those undergoing adenotonsillectomy and 39.6% of those who were referred to the PICU) had respiratory complications. Of those 21, 12 were male. The mean age was 5.3 ± 2.6 years. A high apnea-hypopnea index (AHI; p = 0.0269), a high oxygen desaturation index (ODI; p = 0.0082), a low SpO2 nadir (p = 0.0055), prolonged orotracheal intubation (p = 0.0011), and rhinitis (p = 0.0426) were found to be independent predictors of respiratory complications. Some of the complications observed were minor (SpO2 90-80%), whereas others were major (SpO2 ≤ 80%, laryngospasm, bronchospasm, acute pulmonary edema, pneumonia, and apnea). CONCLUSIONS: Among children up to 12 years of age with OSA, those who have a high AHI, a high ODI, a low SpO2 nadir, or rhinitis are more likely to develop respiratory complications after adenotonsillectomy than are those without such characteristics.
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Mahant S, Keren R, Localio R, Luan X, Song L, Shah SS, Tieder JS, Wilson KM, Elden L, Srivastava R. Variation in quality of tonsillectomy perioperative care and revisit rates in children's hospitals. Pediatrics 2014; 133:280-8. [PMID: 24446446 DOI: 10.1542/peds.2013-1884] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe the quality of care for routine tonsillectomy at US children's hospitals. METHODS We conducted a retrospective cohort study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 US children's hospitals that submit data to the Pediatric Health Information System Database. We assessed quality of care by measuring evidence-based processes suggested by national guidelines, perioperative dexamethasone and no antibiotic use, and outcomes, 30-day tonsillectomy-related revisits to hospital. RESULTS Of 139,715 children who underwent same-day tonsillectomy, 10,868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%-98.8%) and antibiotics (median 16.3%, range 2.7%-92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10-18 vs 1-3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P < .001) across hospitals in total revisits (median 7.8%, range 3.0%-12.6%), revisits for bleeding (median 3.0%, range 1.0%-8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%-4.4%). CONCLUSIONS Substantial variation exists in the quality of care for routine tonsillectomy across US children's hospitals as measured by perioperative dexamethasone and antibiotic use and revisits to hospital. These data on evidence-based processes and relevant patient outcomes should be useful for hospitals' tonsillectomy quality improvement efforts.
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Affiliation(s)
- Sanjay Mahant
- Division of Pediatric Medicine, Pediatric Outcomes Research Team (PORT), Department of Pediatrics, Institute of Health Policy, Evaluation and Management, University of Toronto, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Canada
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Kieran S, Gorman C, Kirby A, Oyemwense N, Lander L, Schwartz M, Roberson D. Risk factors for desaturation after tonsillectomy: analysis of 4092 consecutive pediatric cases. Laryngoscope 2013; 123:2554-9. [PMID: 23686415 DOI: 10.1002/lary.23956] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 11/09/2012] [Accepted: 11/29/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS To identify clinical risk factors for oxygen desaturation in the first 24 hours post-tonsillectomy, thus permitting the identification of those patients who warrant inpatient monitoring. STUDY DESIGN A retrospective analysis of 4092 consecutive patients undergoing tonsillectomy over a two-year period. METHODS Detailed clinical data were recorded for all patients who desaturated in the postoperative period (n = 294) and randomly selected controls (n = 368). Univariate and multivariate analysis was performed in order to identify independent risk factors for desaturation. RESULTS There were 294/4092 patients (7.2%) who experienced desaturations (defined as sustained saturations <90%) in the first 24 hours postoperatively (mean nadir, 78.7%). Multivariate analysis identified seven independent clinical risk factors for desaturation in the initial 24 hours post-tonsillectomy: trisomy 21, weight, coexistent cardiac disease, a coexistent syndromic diagnosis, a clinical diagnosis of obstructive sleep apnea (OSA), a coexistent neurologic diagnosis, and a prior diagnosis of pulmonary disease. A policy that admits all patients exhibiting any one of these risk factors except OSA would have identified 92% of the patients who subsequently desaturated. However, such a policy would also have required admission of 60% of the patients in our control group. CONCLUSIONS These findings are generally consistent with the Clinical Practice Guidelines recently published by the American Academy of Otolaryngology. In a tertiary care center, it may not be possible to identify an algorithm that admits all children at risk of desaturation while permitting the discharge of a high percentage of patients. LEVEL OF EVIDENCE 3b.
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Affiliation(s)
- Stephen Kieran
- Department of Otolaryngology, Children's Hospital Boston, Boston, Massachusetts; Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
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Setabutr D, Patel H, Choby G, Carr MM. Predictive factors for prolonged hospital stay in pediatric tonsillectomy patients. Eur Arch Otorhinolaryngol 2012; 270:1775-81. [DOI: 10.1007/s00405-012-2188-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 09/07/2012] [Indexed: 11/30/2022]
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Mattila PS. Role of adenoidectomy in otitis media and respiratory function. Curr Allergy Asthma Rep 2011; 10:419-24. [PMID: 20721647 DOI: 10.1007/s11882-010-0138-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adenoidectomy is among the most frequent surgical procedures performed on children. The rationale for adenoidectomy is to remove a chronically infected or enlarged and obstructing adenoid. Adenoidectomies are performed on children who have recurrent or chronic otitis media with effusion, on children with chronic rhinosinusitis, and on children with nasopharyngeal obstruction causing sleep disturbances and continuous mouth breathing. Various underlying factors that lead to adenoidectomy are also associated with asthma. Asthma is associated with recurrent respiratory tract infections predisposing individuals to recurrent or chronic otitis media and chronic rhinosinusitis. Children with asthma also have an increased risk of sleep-disordered breathing that is treated with adenoidectomy in the presence of nasopharyngeal obstruction. In nonasthmatic children, adenoidectomy does not influence the development of IgE-mediated allergy, bronchial hyperreactivity, or exhaled nitric oxide concentrations, all of which are surrogate asthma markers. Adenoidectomy in selected asthmatic children may relieve comorbidities associated with asthma.
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Affiliation(s)
- Petri S Mattila
- Department of Otorhinolaryngology, Helsinki University Central Hospital, Finland.
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Schroeder JW, Anstead AS, Wong H. Complications in children who electively remain intubated after adenotonsillectomy for severe obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2009; 73:1095-9. [PMID: 19467719 DOI: 10.1016/j.ijporl.2009.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 04/05/2009] [Accepted: 04/07/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the indications for and the postoperative course of children who are electively left intubated postoperatively vs. those who are not after urgent adenotonsillectomy (T&A) for severe Obstructive Sleep Apnea (OSA). METHODS A retrospective study of children with severe OSA diagnosed by polysomnogram (PSG) who were admitted to the Pediatric Intensive Care Unit (PICU) after urgent adenotonsellectomy between January 2002 and June 2006. Those who were electively left intubated after surgery were compared to those who were extubated. RESULTS n=70. Fifty-three were extubated postoperatively. Seventeen remained intubated. All were admitted to the PICU postoperatively. Method of tonsillectomy and PSG indices were not significantly different between the two groups. Children who remained intubated had a higher complication rate (47%) than those who did not (2%). Children who remained intubated were younger and had a higher ASA (American Society of Anesthesiologist) physician status classification and had a longer PICU and hospital stay. Children under three who were extubated did not require reintubation. CONCLUSIONS Children who electively remain intubated after urgent adenotonsellectomy for severe OSA have a higher complication rate and require a longer hospital stay than those who are extubated. None of the extubated children required reintubation. We recommend a trial of extubation in these patients.
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Affiliation(s)
- James W Schroeder
- Children's Memorial Hospital, Chicago, Pediatric Otolaryngology, Chicago, IL 60614, USA.
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Sleep-Related Breathing Disorders of Childhood: Description and Clinical Picture, Diagnosis, and Treatment Approaches. Sleep Med Clin 2007. [DOI: 10.1016/j.jsmc.2007.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Cervera Escario J, Del Castillo Martín F, Gómez Campderá JA, Gras Albert JR, Pérez Piñero B, Villafruela Sanz MA. Indicaciones de Adenoidectomía y Amigdalectomía: Documento de Consenso entre la Sociedad Española de Otorrinolaringología y Patología Cervicofacial y la Asociación Española de Pediatría. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2006; 57:59-65. [PMID: 16550858 DOI: 10.1016/s0001-6519(06)78665-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Tonsillectomy and adenoidectomy are probably the commonest surgeries performed in the ENT field as well as the most controversial ones. There are very few consensus documents available for these two surgeries. In 1997 a document written by the two mentioned Societies was published, in order to update such document regarding tonsillectomy and adenoidectomy procedures we have met this year representatives from both scientific societies and a new document has been elaborated. We describe the diagnostic criteria of pharyngo-tonsillitis and adenoiditis as well as of obstructive sleep apnoea syndrome, with the aim of a better comprehension of these processes when a decision needs to be made regarding surgery. Indications and contraindications of tonsillectomy and adenoidectomy are here described.
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