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Lee CW, Ivy A, Brownlee B, Bahgat M, Waters A, Pabla L, McLarnon C, Siou G, Powell S. How Do We Safely Increase Day-Case Tonsillectomy for the Treatment of Paediatric Obstructive Sleep Apnoea-A Cohort Analysis. Clin Otolaryngol 2024. [PMID: 39030962 DOI: 10.1111/coa.14200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 05/12/2024] [Accepted: 07/06/2024] [Indexed: 07/22/2024]
Affiliation(s)
- Chang Woo Lee
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Ashleigh Ivy
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Brittany Brownlee
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mohammed Bahgat
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Aoife Waters
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Lakhbinder Pabla
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Claire McLarnon
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Gerard Siou
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Allard A, Valois-Demers J, Pellerin A, Leclerc JE, Cloutier K. Evaluation of Postoperative Efficacy and Safety of Celecoxib in Children Hospitalized After Adenotonsillectomy. J Pediatr Pharmacol Ther 2024; 29:255-265. [PMID: 38863864 PMCID: PMC11163914 DOI: 10.5863/1551-6776-29.3.255] [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: 04/26/2023] [Accepted: 09/04/2023] [Indexed: 06/13/2024]
Abstract
OBJECTIVE The choice of optimal analgesia following an adenotonsillectomy is a clinical issue because of the risk of respiratory depression and bleeding. The objective of this study was to assess the effect of celecoxib on opioid use and pain scores in children hospitalized after adenotonsillectomy and to document its adverse effects. METHODS This retrospective study was conducted in a tertiary care pediatric hospital. We compared a group of subjects aged 1 to 17 years who were prescribed celecoxib and opioids between January 2017 and June 2020 following an adenotonsillectomy during a 3-day or less hospitalization to a group of matched controls for sex, age, and length of stay who were prescribed opioids. RESULTS A total of 228 patients were identified (76 in the celecoxib + opioids group, 152 in the control group). Opioid use, in oral morphine equivalent daily dose, was lower in the celecoxib + opioids group at 0 to 24 hours of hospitalization (0.15 vs 0.20 mg/kg/day, p = 0.05). Initiating celecoxib within 24 hours of surgery (n = 60) significantly reduced opioid requirement for up to 48 hours compared with controls (0-24 hours: 0.12 vs 0.20 mg/kg/day, p = 0.002; 25-48 hours: 0.02 vs 0.09 mg/kg/day, p = 0.001). A shorter length of stay was observed for patients receiving celecoxib + opioids during the first 24-hour post--operative period (27 vs 32 hours, p = 0.01). With celecoxib use, no significant change in pain scores and occurrence of adverse effects including bleeding was found. CONCLUSIONS Using celecoxib early after an adenotonsillectomy has reduced both opioid use and duration of hospital stay without increasing adverse effects or bleeding.
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Affiliation(s)
- Audrey Allard
- Candidate for the Master's program in Advanced Pharmacotherapy at the time of writing, Faculty of Pharmacy, Université Laval, Quebec, Canada (AA), pharmacy resident at the time of writing, Centre hospitalier de l’Université Laval, CHU de Québec-Université Laval, Quebec, QC (AA)
| | - Julien Valois-Demers
- Department of Pharmacy (JVD, AP, KC) Centre Mère-Enfant Soleil of the Centre hospitalier de l’Université Laval, CHU de Québec-Université Laval, Quebec, QC, Canada
- Faculty of Pharmacy, Université Laval, Quebec, Canada (JVD, AP, KC), Faculty of Medicine, Université Laval, Quebec, Canada (JEL)
| | - Annie Pellerin
- Department of Pharmacy (JVD, AP, KC) Centre Mère-Enfant Soleil of the Centre hospitalier de l’Université Laval, CHU de Québec-Université Laval, Quebec, QC, Canada
- Faculty of Pharmacy, Université Laval, Quebec, Canada (JVD, AP, KC), Faculty of Medicine, Université Laval, Quebec, Canada (JEL)
| | - Jacques E. Leclerc
- Department of Otorhinolaryngology (JEL) Centre Mère-Enfant Soleil of the Centre hospitalier de l’Université Laval, CHU de Québec-Université Laval, Quebec, QC, Canada
- Faculty of Pharmacy, Université Laval, Quebec, Canada (JVD, AP, KC), Faculty of Medicine, Université Laval, Quebec, Canada (JEL)
| | - Karine Cloutier
- Department of Pharmacy (JVD, AP, KC) Centre Mère-Enfant Soleil of the Centre hospitalier de l’Université Laval, CHU de Québec-Université Laval, Quebec, QC, Canada
- Faculty of Pharmacy, Université Laval, Quebec, Canada (JVD, AP, KC), Faculty of Medicine, Université Laval, Quebec, Canada (JEL)
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Mussi N, Forestiero R, Zambelli G, Rossi L, Caramia MR, Fainardi V, Esposito S. The First-Line Approach in Children with Obstructive Sleep Apnea Syndrome (OSA). J Clin Med 2023; 12:7092. [PMID: 38002704 PMCID: PMC10672526 DOI: 10.3390/jcm12227092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSA) is the main manifestation of sleep-disordered breathing in children. Untreated OSA can lead to a variety of complications and adverse consequences mainly due to intermittent hypoxemia. The pathogenesis of OSA is multifactorial. In children aged 2 years or older, adenoid and/or tonsil hypertrophy are the most common causes of upper airway lumen reduction; obesity becomes a major risk factor in older children and adolescents since the presence of fat in the pharyngeal soft tissue reduces the caliber of the lumen. Treatment includes surgical and non-surgical options. This narrative review summarizes the evidence available on the first-line approach in children with OSA, including clinical indications for medical therapy, its effectiveness, and possible adverse effects. Literature analysis showed that AT is the first-line treatment in most patients with adenotonsillar hypertrophy associated with OSA but medical therapy in children over 2 years old with mild OSA is a valid option. In mild OSA, a 1- to 6-month trial with intranasal steroids (INS) alone or in combination with montelukast with an appropriate follow-up can be considered. Further studies are needed to develop an algorithm that permits the selection of children with OSA who would benefit from alternatives to surgery, to define the optimal bridge therapy before surgery, to evaluate the long-term effects of INS +/- montelukast, and to compare the impact of standardized approaches for weight loss.
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Affiliation(s)
| | | | | | | | | | | | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (N.M.); (R.F.); (G.Z.); (L.R.); (M.R.C.); (V.F.)
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Arens P, Hardt J, Angrick JC, Olze H, Coordes A. Modified dindo-clavien system for registration of perioperative complications in children undergoing adenotonsillectomy. Front Pediatr 2022; 10:1049942. [PMID: 36644402 PMCID: PMC9837099 DOI: 10.3389/fped.2022.1049942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/28/2022] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Surgical procedures in children are among the most commonly performed procedures in otolaryngology. Perioperative safety and documentation of complications are becoming increasingly important. This study investigates perioperative complications in a clinical cohort of children with adenotonsillar hyperplasia undergoing adenotonsillectomy using the standardized Dindo-Clavien reporting system. PATIENTS AND METHODS Retrospective evaluation of 402 children who underwent adenotonsillectomy between 2009 and 2015. Patient parameters including all perioperative complications were investigated. RESULTS In the study, 124 complications were found (106 mild, 16 severe). According to the Dindo-Clavien classification, 93 grade I, 15 grade II, 5 grade III, 11 grade IV and 0 grade V complications were documented. Complications were associated with additional diagnoses (p = 0.001), long-term medication intake (p = 0.003), duration of hospitalization (p < 0.001) and duration of surgery (p < 0.001), undergoing tonsillotomy (p = 0.022) or tonsillectomy (p < 0.001), differences in ASA score (p = 0.005) and differences in OSA-18 score (p = 0.011). Severe complications, classified as grade III and IV, were associated with premature birth (p = 0.026), additional diagnoses (p = 0.017), long-term medication intake (p < 0.001) and differences in ASA score (p =< 0.001). CONCLUSION The Dindo-Clavien classification is a standardized reporting system which can also be used for surgical procedures in children with adenotonsillar hyperplasia. The system shows associations with clinical parameters and thus can help to identify subgroups at risk of severe complications.
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Affiliation(s)
- Philipp Arens
- Department of Otorhinolaryngology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Juliane Hardt
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Institute for Integrative Medicine, Department for Human Medicine, Faculty of Health, Witten/Herdecke University, Herdecke, Germany
| | - Julie Charlotte Angrick
- Department of Otorhinolaryngology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Heidi Olze
- Department of Otorhinolaryngology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Annekatrin Coordes
- Department of Otorhinolaryngology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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McGuire SR, Doyle NM. Update on the safety of anesthesia in young children presenting for adenotonsillectomy. World J Otorhinolaryngol Head Neck Surg 2021; 7:179-185. [PMID: 34430825 PMCID: PMC8356117 DOI: 10.1016/j.wjorl.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 11/17/2022] Open
Abstract
Tonsillectomy with and without adenoidectomy is a frequently performed surgical procedure in children. Although a common procedure, it is not without significant risk. It is critical for anesthesiologists to consider preoperative, intraoperative, and postoperative patient factors and events to optimize safety, especially in young children. In the majority of cases, the indication for adenotonsillectomy in young children is obstructive breathing. Preoperative evaluation for patient comorbidities, especially obstructive sleep apnea, risk factors for a difficult airway, and history of recent illness are crucial to prepare the patient for surgery and develop an anesthetic plan. Communication and collaboration with the otolaryngologist is key to prevent and treat intraoperative events such as airway fires or hemorrhage. Postoperative analgesia planning is critical for safe pain control especially for those patients with a history of obstructive sleep apnea and opioid sensitivity. In young children, it is important to also consider the impact of anesthetic medications on the developing brain. This is an area of continuing research but needs to be weighed when planning for surgical treatment and when discussing risks and benefits with patients' families.
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Affiliation(s)
- Stephanie R. McGuire
- Corresponding author. Department of Anesthesiology, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO, 64108, USA.
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Packiasabapathy S, Zhang X, Ding L, Aruldhas BW, Pawale D, Sadhasivam S. Quantitative Pupillometry as a Predictor of Pediatric Postoperative Opioid-Induced Respiratory Depression. Anesth Analg 2021; 133:991-999. [PMID: 34029273 DOI: 10.1213/ane.0000000000005579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Safe postoperative pain relief with opioids is an unmet critical medical need in children. There is a lack of objective, noninvasive bedside tool to assess central nervous system (CNS) effects of intraoperative opioids. Proactive identification of children at risk for postoperative respiratory depression (RD) will help tailor analgesic therapy and significantly improve the safety of opioids in children. Quantitative pupillometry (QP) is a noninvasive, objective, and real-time tool for monitoring CNS effect-time relationship of opioids. This exploratory study aimed to determine the association of QP measures with postoperative RD, as well as to identify the best intraoperative QP measures predictive of postoperative RD in children. METHODS After approval from the institutional review board and informed parental consent, in this prospective, observational study of 220 children undergoing tonsillectomy, QP measures were collected at 5 time points: awake preoperative baseline before anesthesia induction (at the time of enrollment [T1]), immediately after anesthesia induction before morphine administration (T2), 3 minutes after intraoperative morphine administration (T3), at the end of surgery (T4), and postoperatively when awake in postanesthesia recovery unit (PACU) (T5). Intraoperative use of opioid and incidence of postoperative RD were collected. Analyses were aimed at exploring correlations of QP measures with the incidence of RD and, if found significant, to develop a predictive model for postoperative RD. RESULTS Perioperative QP measures of percentage pupil constriction (CONQ, P = .027), minimum pupillary diameter (MIN, P = .027), and maximum pupillary diameter (MAX, P = .034) differed significantly among children with and without postoperative RD. A predictive model including the minimum pupillary diameter 3 minutes after morphine administration (MIN3), minimum pupillary diameter normalized to baseline (MIN31), and percentage pupillary constriction after surgery (T4) standardized to baseline (T1) (CONQ41), along with the weight-based morphine dose performed the best to predict postoperative RD in children (area under the curve [AUC], 0.76). CONCLUSIONS A model based on pre- and intraoperative pupillometry measures including CONQ, MIN, along with weight-based morphine dose-predicted postoperative RD in our cohort of children undergoing tonsillectomy. More studies with a larger sample size are required to validate this finding.
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Affiliation(s)
- Senthil Packiasabapathy
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Lili Ding
- Division of Human Genetics.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Blessed W Aruldhas
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana.,Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, India
| | - Dhanashri Pawale
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Senthilkumar Sadhasivam
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
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Guo J, Zhuang P, Liu K, Wan Y, Wang X. Effects of an individualized analgesia protocol on the need for medical interventions after adenotonsillectomy in children: a randomized controlled trial. BMC Anesthesiol 2021; 21:41. [PMID: 33557762 PMCID: PMC7869251 DOI: 10.1186/s12871-021-01263-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/14/2021] [Indexed: 11/22/2022] Open
Abstract
Background It has been proposed that the dose of rescue opioids should be individually titrated to the severity of obstructive sleep apnea after adenotonsillectomy. However, a sleep study is not always available before adenotonsillectomy. This randomized, controlled and blinded trial evaluated a strategy of pain control individualized to the results of a fentanyl test, rather than the results of polysomnography, in children after adenotonsillectomy. Methods A total of 280 children (3–10 years old) undergoing elective adenotonsillectomy were randomized into an individualized protocol (IP) group or a conservative protocol (CP) group. All patients received a fentanyl test before extubation. Pain was assessed every 10 min in the recovery room, and rescue morphine was given when the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) score was > 6. In the IP group, the dose of rescue morphine was individualized to the results of the fentanyl test (10 μg/kg in the case of a positive result and 50 μg/kg in the case of a negative result). In the CP group, the dose was fixed (25 μg/kg). The primary outcome was the percentage of patients requiring at least one medical intervention. The secondary outcome was the median duration of CHEOPS scores > 6. Results Fewer patients in the IP group than in the CP group required medical interventions [11.9% (16/134) vs 22.3% (29/130), P = 0.025]. The median duration of CHEOPS scores > 6 was shorter in the IP group than in the CP group [20 (95% CI: 17 to 23) min vs 30 (95% CI: 28 to 32) min, P < 0.001]. Conclusions Compared with a conservative dosing approach, this individualized protocol may improve analgesia without a significant increase in respiratory adverse events. Trial registration ClinicalTrials.gov NCT02990910, registered on 13/12/2016.
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Affiliation(s)
- Jian Guo
- Department of Anesthesia, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Peijun Zhuang
- Department of Anesthesia, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Kun Liu
- Department of Anesthesia, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Yuanyuan Wan
- Department of Anesthesia, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China
| | - Xuan Wang
- Department of Anesthesia, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102, China.
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Huang Q, Hua H, Li W, Chen X, Cheng L. Simple hypertrophic tonsils have more active innate immune and inflammatory responses than hypertrophic tonsils with recurrent inflammation in children. J Otolaryngol Head Neck Surg 2020; 49:35. [PMID: 32487224 PMCID: PMC7268328 DOI: 10.1186/s40463-020-00428-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 05/18/2020] [Indexed: 12/26/2022] Open
Abstract
Background Tonsil hypertrophy has negative impact on children’s health, but its pathogenesis remains obscure despite the fact that numerous bacteriological studies have been carried out. Understanding the innate immune and inflammatory states of hypertrophic tonsils with different clinical manifestations is of great significance for defining the pathogenesis of tonsil hypertrophy and establishing treatment strategies. The present study was undertaken to examine the characteristics of innate immunity and inflammation in children with hypertrophic palatine tonsils and different clinical manifestations. Methods Tonsil tissues were surgically removed from the patients and classified based on the patients’ clinical manifestations. The patients were divided into three groups: 1) Control group; 2) Tonsil Hypertrophy (TH) group; and 3) Tonsil Hypertrophy combined with Recurrent Infection (TH + RI) group. The immune and inflammatory statuses of these tissues were characterized using qRT-PCR and ELISA methods. Results Viral protein 1 (VP1) was highly expressed in TH group, but not in TH + RI group. In TH group, elevated expression was observed in the innate immune mediators, including retinoic acid-inducible gene I (RIG-I), interferon alpha (IFN-α), mitochondrial antiviral-signaling protein (MAVS), NLR family pyrin domain containing 3 (NLRP3), toll-like receptor (TLR) 4 and TLR7. Consistent with the innate immune profile, the expression of inflammatory markers (IL-1β, NF-κB and IL-7) was also significantly elevated in TH group. Meanwhile, the COX-2/PGE2/EP4 signaling pathway was found to be involved in the inflammatory response and the formation of fibroblasts. Conclusions Innate immune and inflammatory responses are more active in simple hypertrophic tonsils, rather than hypertrophic tonsils with recurrent inflammation. A local relative immune deficiency in the hypertrophic tonsils may be a causative factor for recurrent tonsillitis in TH + RI. These differences, together with the patient’s clinical manifestations, suggest that tonsillar hypertrophy might be regulated by diverse immune and/or inflammatory mechanism through which novel therapeutic strategies might be created.
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Affiliation(s)
- Qun Huang
- Department of Otorhinolaryngology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hu Hua
- Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Li
- Department of Otorhinolaryngology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xi Chen
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Lei Cheng
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
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Ekstein M, Zac L, Schvartz R, Goren O, Weiniger CF, DeRowe A, Fishman G. Respiratory complications after adenotonsillectomy in high-risk children with obstructive sleep apnea: A retrospective cohort study. Acta Anaesthesiol Scand 2020; 64:292-300. [PMID: 31587265 DOI: 10.1111/aas.13488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/21/2019] [Accepted: 09/22/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) occurs in 1%-4% of children; adenotonsillectomy is an effective treatment. Mortality/severe brain injury occurs among 0.6/10 000 adenotonsillectomies; in children, 60% are secondary to airway/respiratory events. Earlier studies identified that children aged <2 years, extremes of weight, with co-morbidities of craniofacial, neuromuscular, cardiac/respiratory disease, or severe OSA are at high risk for adverse post-operative respiratory events (AE). We aimed to: Firstly, investigate which risk factors were associated with AEs either in the post-anesthesia care unit (PACU), pediatric intensive care unit (PICU), or both in this population. Secondly, we investigated factors associated with post-operative PICU AE despite no event in the PACU in order to predict need of post-operative PICU after their PACU stay. METHODS Retrospective study of children admitted to the PICU after adenotonsillectomy between 08/2006-09/2015. Demographics, risk factors, and occurrence of AE (oxygen saturation <92, stridor, bronchospasm, pneumonia, pulmonary edema, re-intubation) were recorded. RESULTS During the studied time period 4029 tonsil/adenoid procedures were performed in 3997 children. 179, admitted to the PICU post-operatively, met criteria for analysis. PICU AEs occurred in 59%: 44%-83% in any particular risk category. PACU AEs occurred in 42%. Of those with PACU events: 92% suffered AEs in the PICU; however, 35% of those without a PACU AE still suffered a PICU AE. CONCLUSIONS Among high-risk children undergoing TA, absence of adverse events in PACU during a 2-hour observation period does not predict absence of subsequent AEs in the PICU.
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Affiliation(s)
- Margaret Ekstein
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Lilach Zac
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Reut Schvartz
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Or Goren
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Carolyn F. Weiniger
- Division of Anesthesiology, Intensive Care, and Pain Medicine Sackler Faculty of Medicine Tel‐Aviv Medical Center Tel‐Aviv University Tel Aviv Israel
| | - Ari DeRowe
- Department of Otolaryngology Head and Neck and Maxillofacial Surgery, Pediatric Otolaryngology Unit Tel Aviv Medical Center Dana-Dwek Children’s Hospital Tel Aviv Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
| | - Gad Fishman
- Department of Otolaryngology Head and Neck and Maxillofacial Surgery, Pediatric Otolaryngology Unit Tel Aviv Medical Center Dana-Dwek Children’s Hospital Tel Aviv Sackler School of Medicine, Tel Aviv University Tel Aviv Israel
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Long-term neurocognitive impairment after general anaesthesia in childhood: Is obstructive sleep apnoea to blame? Eur J Anaesthesiol 2019; 36:719-720. [PMID: 31483343 DOI: 10.1097/eja.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Roberts C, Al Sayegh R, Ellison PR, Sedeek K, Carr MM. How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy. Ann Otol Rhinol Laryngol 2019; 129:55-62. [PMID: 31801377 DOI: 10.1177/0003489419874371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA). STUDY DESIGN Online survey. METHOD A sample of pediatric anesthesiologists received the survey by email. RESULTS 110 respondents were included. 46.4% worked in a free-standing children's hospital and 32.7% worked in a children's facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children's hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA (P < 0.05). CONCLUSION Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.
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Affiliation(s)
- Christopher Roberts
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, West Virginia University, Morgantown, WV, USA
| | | | | | - Khaled Sedeek
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - Michele M Carr
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, West Virginia University, Morgantown, WV, USA
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Galvez JA, Yaport M, Maeder-Chieffo S, Simpao AF, Tan JM, Wasey JO, Lingappan AM, Jablonka DH, Subramanyam R, Ahumada LM, Song B, Wu L, Dubow S, Rehman MA. STBUR: Sleep trouble breathing and unrefreshed questionnaire: Evaluation of screening tool for postanesthesia care and disposition. Paediatr Anaesth 2019; 29:821-828. [PMID: 31124263 DOI: 10.1111/pan.13660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 04/19/2019] [Accepted: 05/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire is a five-question screening tool for pediatric sleep-disordered breathing and risk for perioperative respiratory adverse events in children. The utility of this questionnaire as a preoperative risk-stratification tool has not been investigated. In view of limited availability of screening tools for preoperative pediatric sleep-disordered breathing, we evaluated the questionnaire's performance for postanesthesia adverse events that can impact postanesthesia care and disposition. METHODS The retrospective study protocol was approved by the institutional research board. The data were analyzed using two different definitions for a positive screening based on a five-point scale: low threshold (scores 1 to 5) and high threshold (score of 5). The primary outcome was based on the following criteria: (a) supplemental oxygen therapy following postanesthesia care unit (PACU) stay until hospital discharge, (b) greater than two hours during phase 1 recovery, (c) anesthesia emergency activation in the PACU, and (d) unplanned hospital admission. RESULTS About 6025 patients completed the questionnaire during the preoperative evaluation. And 1522 patients had a low threshold score and 270 had a high-threshold score. We found statistically significant associations in three outcomes based on the low threshold score: supplemental oxygen therapy (negative-predictive value [NPV] 0.97, 95% CI 0.97-98), PACU recovery time (NPV 0.99, 95% CI 0.99-0.99) and escalation of care (NPV 0.98, 95% CI 0.97-0.98). Positive-predictive values were statistically significant for all outcomes except anesthesia emergency in the PACU. CONCLUSION The Snoring, Trouble Breathing, and Un-Refreshed questionnaire identified patients at higher risk for prolonged phase 1 recovery, oxygen therapy requirement, and escalation of care. The questionnaire's high-negative predictive value and specificity may make it useful as a screening tool to identify patients at low risk for prolonged stay in PACU.
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Affiliation(s)
- Jorge A Galvez
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Miguel Yaport
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Susan Maeder-Chieffo
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allan F Simpao
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jonathan M Tan
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jack O Wasey
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Arul M Lingappan
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Denis H Jablonka
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rajeev Subramanyam
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Luis M Ahumada
- Enterprise Analytics and Reporting, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bo Song
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,College of Computing & Informatics, Drexel University, Philadelphia, Pennsylvania
| | - Lezhou Wu
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Scott Dubow
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Mohamed A Rehman
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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SÁNCHEZ-SERRANO A, CALVO-BOIZAS E, MORALES-MARTÍN AC, SÁNCHEZ-VELEZ T, FERNÁNDEZ-SÁNCHEZ JL, BENITO-GONZÁLEZ F, DIEGO-PÉREZ C, GIL-MELCÓN M, SÁNCHEZ-BARRADO E, MORÁN-SÁNCHEZ JC, MARÍN-CASSINELLO A, DE PAZ-SÁNCHEZ A, BLANCO-RUEDA JA, VÁZQUEZ-CASARES G, MARTÍN-GÓMEZ MC, SANTOS-GORJÓN P, BARAJAS-SÁNCHEZ V. Guía de práctica clínica para el diagnóstico y tratamiento quirúrgico del síndrome de apnea obstructiva del sueño en pacientes de dos a ocho años de edad. REVISTA ORL 2019. [DOI: 10.14201/orl.20736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Alsuhebani M, Walia H, Miller R, Elmaraghy C, Tumin D, Tobias JD, Raman VT. Overnight inpatient admission and revisit rates after pediatric adenotonsillectomy. Ther Clin Risk Manag 2019; 15:689-699. [PMID: 31239691 PMCID: PMC6560194 DOI: 10.2147/tcrm.s185193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 03/31/2019] [Indexed: 11/28/2022] Open
Abstract
Objective: Overnight admission may be necessary following adenotonsillectomy (T&A) in pediatric patients. This practice may reduce unplanned revisits following hospital discharge. Study design: Retrospective cohort study. Subjects: Children from the PHIS database. Methods: T&A performed in children during the years 2007–2015 were identified in the Pediatric Health Information System. The primary outcome was 7-day, all-cause readmission or emergency department (ED) revisit. Secondary analysis examined specific revisit types and 30-day revisits. The primary exposure was each institution’s annual rate of overnight stay after T&A. Results: The analysis included 411,876 procedures at 48 hospitals. Hospitals’ annual rates of overnight stay following T&A ranged from 3% to 100%, and 7-day revisit rates varied from 0% to 15%. The percentage or rate of 7-day revisits did not differ based on the use of overnight stay following T&A. At hospitals with higher overnight admission rates after T&A, 7-day revisits were more likely to take the form of inpatient admission rather than an ED visit. Conclusions: The current study confirms that pediatric hospitals vary widely in inpatient admission practices following T&A. This variation is not associated with differences in revisit rates at 7 and 30 days related to any cause. Although no mortality was noted in the current study, caution is suggested when deciding on the disposition of patients with comorbid conditions as risks related to various patients, anesthetic, and surgical-related issues exist. Risk stratification with appropriate identification of patients requiring overnight stay may be the most important for preventing acute care revisits after T&A.
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Affiliation(s)
- Mohammad Alsuhebani
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Hina Walia
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rebecca Miller
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles Elmaraghy
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Ear, Nose & Throat Surgery, The Ohio State University, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Vidya T Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
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15
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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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16
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Montana MC, Juriga L, Sharma A, Kharasch ED. Opioid Sensitivity in Children with and without Obstructive Sleep Apnea. Anesthesiology 2019; 130:936-945. [DOI: 10.1097/aln.0000000000002664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Opioids are a mainstay of perioperative analgesia. Opioid use in children with obstructive sleep apnea is challenging because of assumptions for increased opioid sensitivity and assumed risk for opioid-induced respiratory depression compared to children without obstructive sleep apnea. These assumptions have not been rigorously tested. This investigation tested the hypothesis that children with obstructive sleep apnea have an increased pharmacodynamic sensitivity to the miotic and respiratory depressant effects of the prototypic μ-opioid agonist remifentanil.
Methods
Children (8 to 14 yr) with or without obstructive sleep apnea were administered a 15-min, fixed-rate remifentanil infusion (0.05, 0.1, or 0.15 μg · kg-1 · min-1). Each dose group had five patients with and five without obstructive sleep apnea. Plasma remifentanil concentrations were measured by tandem liquid chromatography mass spectrometry. Remifentanil effects were measured via miosis, respiratory rate, and end-expired carbon dioxide. Remifentanil pharmacodynamics (miosis vs. plasma concentration) were compared in children with or without obstructive sleep apnea.
Results
Remifentanil administration resulted in miosis in both non-obstructive sleep apnea and obstructive sleep apnea patients. No differences in the relationship between remifentanil concentration and miosis were seen between the two groups at any of the doses administered. The administered dose of remifentanil did not affect respiratory rate or end-expired carbon dioxide in either group.
Conclusions
No differences in the remifentanil concentration–miosis relation were seen in children with or without obstructive sleep apnea. The dose and duration of remifentanil administered did not alter ventilatory parameters in either group.
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Affiliation(s)
- Michael C. Montana
- From the Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri (M.C.M., L.J., A.S., E.D.K.); and the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (E.D.K.)
| | - Lindsay Juriga
- From the Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri (M.C.M., L.J., A.S., E.D.K.); and the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (E.D.K.)
| | - Anshuman Sharma
- From the Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri (M.C.M., L.J., A.S., E.D.K.); and the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (E.D.K.)
| | - Evan D. Kharasch
- From the Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri (M.C.M., L.J., A.S., E.D.K.); and the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (E.D.K.)
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17
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Elphick H, Watson-Thoday E, Kingshott R, Schofield R, Smith M, Edwards C, Thevasagayam M. Are sleep studies necessary prior to adenotonsillectomy? A retrospective case-controlled study of eighty-two children. Clin Otolaryngol 2019; 44:667-670. [PMID: 31006172 DOI: 10.1111/coa.13346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/03/2019] [Accepted: 03/24/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Heather Elphick
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Emily Watson-Thoday
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Ruth Kingshott
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Robert Schofield
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Matthew Smith
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Christopher Edwards
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Mahilravi Thevasagayam
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
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18
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Bromwich M. Tonsillectomy or adenotonsillectomy versus nonsurgical management for obstructive sleep-disordered breathing in children. Paediatr Child Health 2018; 23:388-390. [PMID: 30455576 DOI: 10.1093/pch/pxy048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Matthew Bromwich
- Clinical Research Unit, CHEO Research Institute, Ottawa, Ontario.,Division of Otolaryngology, Department of Surgery, CHEO, University of Ottawa, Ottawa, Ontario
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19
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Shaw KA, Fletcher ND, Devito DP, Murphy JS. Complications following lengthening of spinal growing implants: is postoperative admission necessary? J Neurosurg Pediatr 2018; 22:102-107. [PMID: 29701559 DOI: 10.3171/2018.2.peds1827] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of postoperative admission status on 30-day perioperative complications in patients with growing spinal instrumentation undergoing surgical lengthening. METHODS This retrospective case-control study of records from the 2014-2015 National Surgical Quality Improvement Program-Pediatric database was performed to identify surgical lengthening procedures of spinal implants in patients with growing instrumentation by Current Procedural Terminology code. The 30-day postoperative complications were classified according to the Clavien-Dindo system. Patients were subdivided according to their postsurgical admission status. Admission status, American Society of Anesthesiologists (ASA) Physical Status classification, tracheostomy, neuromuscular diagnosis, ventilator dependence, and nutritional support were considered as possible risk factors in univariate and multivariate logistic regression analyses. RESULTS A total of 796 patients were identified (mean age 9.09 ± 3.44 years; 54% of patients were female), of whom 73% underwent lengthening on an inpatient basis. Patients with a tracheostomy or ventilator dependence were more likely to be admitted postoperatively. The overall rate of major complications was 3.5% and did not differ based on admission status (2.8% inpatient vs 3.8% outpatient, p = 0.517). On univariate analysis, ventilator dependence (9.5% vs 2.7%, p = 0.002), need for nutritional support (7.1% vs 2.5%, p = 0.006), and ASA class > II (4.8% vs 1.3%, p = 0.04) placed patients at a higher risk for any postoperative complications. Multivariate analysis identified only ventilator dependence as an independent risk factor for any perioperative complication. CONCLUSIONS Postoperative admission status did not affect the rate of 30-day perioperative complications, readmission, or rate of unplanned operations following lengthening of growing spinal instrumentation. Outpatient lengthening appears to be safe; however, consideration for postoperative admission should be given for those who are ventilator dependent.
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Affiliation(s)
- K Aaron Shaw
- 1Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon
| | | | - Dennis P Devito
- 3Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
| | - Joshua S Murphy
- 3Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Georgia
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20
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Research Needs Assessment for Children With Obstructive Sleep Apnea Undergoing Diagnostic or Surgical Procedures. Anesth Analg 2018; 127:198-201. [DOI: 10.1213/ane.0000000000003309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Schnoor J, Busch T, Turemuratov N, Merkenschlager A. Pre-anesthetic assessment with three core questions for the detection of obstructive sleep apnea in childhood: An observational study. BMC Anesthesiol 2018; 18:25. [PMID: 29458333 PMCID: PMC5819204 DOI: 10.1186/s12871-018-0483-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 01/23/2018] [Indexed: 11/25/2022] Open
Abstract
Background Children with obstructive sleep apnea are at high risk for perioperative airway obstruction. Many “at risk” children may remain unrecognized. The aim of this study is to find a clinically practicable test to identify obstructive sleep apnea in childhood. Methods In this pilot study, we prospectively compared four parental questionnaires with the respective findings of subsequent sleep laboratory testing in children. Right before sleep laboratory testing, children’s parents answered both the Pediatric Sleep Questionnaire, a subscale of the Sleep Related Breathing Disorder questionnaire (PSQ-SRBD-Subscale), and an eight-item questionnaire derived from it. Finally, we condensed the eight-item questionnaire to three core issues: Does your child regularly snore at night? Does your child demonstrate labored breathing during sleep? Does your child have breathing pauses during sleep? With it, two similar questionnaires were generated that differed in the formation of the resulting score. One questionnaire was built by a quotient comparable to the abovementioned questionnaires and a second as quick test that functioned as a simple sum score. Both sensitivity and specificity were determined by using a Receiver Operating Characteristic analysis. Results In total, 53 children were included in the study. Both the PSQ-SRBD-questionnaire and self-derived eight-item questionnaire failed to reach statistically significant results in detecting obstructive sleep apnea. The set of three core questions with a score built by a quotient was statistically significant and provided sensitivity and a moderate specificity of 0.944 and 0.543, respectively. This could be slightly optimized by creating a simple sum-score (specificity of 0.571). Conclusions The use of three core-questions may facilitate the detection of pediatric obstructive sleep apnea within the scope of the anesthesia survey. While the study has some limitations, future studies with both unselective collectives and older children might prove this ultra-short questionnaire to be advantageous in detecting pediatric OSA in clinical practices. Trial registration German Clinical Trial Register (DRKS00010408, https://www.drks.de); date of registration 26.07.2016
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Affiliation(s)
- Joerg Schnoor
- Department of Anesthesia and Intensive Care Medicine, Collm-Klinik-Oschatz, Parkstr. 1, 03435, Oschatz, Germany. .,Department of Anesthesia and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Thilo Busch
- Department of Anesthesia and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Nazar Turemuratov
- Department of Anesthesia and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Andreas Merkenschlager
- Department of Neuropediatric, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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22
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Anesthesia for Ears, Nose, and Throat Surgery. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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23
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Thung AK, Elmaraghy CA, Barry N, Tumin D, Jatana KR, Rice J, Raman V, Bhalla T, Martin DP, Corridore M, Tobias JD. Double-Blind Randomized Placebo-Controlled Trial of Single-Dose Intravenous Acetaminophen for Pain Associated With Adenotonsillectomy in Pediatric Patients With Sleep-Disordered Breathing. J Pediatr Pharmacol Ther 2017; 22:344-351. [PMID: 29042835 DOI: 10.5863/1551-6776-22.5.344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Adequate pain control is an important component in the postoperative outcome for pediatric adenotonsillectomy patients with sleep-disordered breathing (SDB). Intravenous acetaminophen appears to be a favorable analgesic adjunct owing to its predictable pharmacokinetics and opioid-sparing effects; however, its role in pediatric adenotonsillectomy pain management remains unclear. METHODS In this prospective, randomized, double-blinded, controlled study, subjects with the diagnosis of SDB, aged 2 to 8 years, who required extended postoperative admission, received intravenous acetaminophen (15 mg/kg) or saline placebo intraoperatively in addition to morphine (0.1 mg/kg) for postoperative surgical analgesia. Pain scores in the postanesthesia care unit (PACU) using the FLACC (Faces, Leg, Activity, Cry, Consolability) score were used to determine the need for supplemental analgesic agents in the PACU. The PACU time and time to the first request for pain medication on the inpatient ward were also measured. RESULTS A total of 239 patients were included in the final data analysis (118 in the intravenous acetaminophen group and 121 in the saline placebo group). The 2 groups did not differ in the proportion of patients reaching FLACC scores = 4 in the PACU (p = 0.223); mean FLACC scores in the PACU (p = 0.336); mean PACU time (p = 0.883); or time to requesting pain medication on the inpatient ward (p = 0.640). CONCLUSIONS A single intraoperative dose of intravenous acetaminophen did not alter the postoperative course of pediatric patients with SDB following adenotonsillectomy.
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Affiliation(s)
- Arlyne K Thung
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - Charles A Elmaraghy
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - N'Diris Barry
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - Kris R Jatana
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Rice
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - Vidya Raman
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - David P Martin
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - Marco Corridore
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine (AKT, N'DB, DT, JR, VR, TB, DPM, MC, JDT), Department of Otolaryngology (CAE, KRJ), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology and Pain Medicine (AKT, DT, VR, TB, DPM, JDT), Department of Otolaryngology (CAE KRJ), The Ohio State University College of Medicine, Columbus, Ohio
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Raman VT, Tumin D, Uffman J, Thung AK, Burrier C, Jatana KR, Elmaraghy C, Tobias JD. Implementation of a perioperative surgical home protocol for pediatric patients presenting for adenoidectomy. Int J Pediatr Otorhinolaryngol 2017; 101:215-222. [PMID: 28964298 DOI: 10.1016/j.ijporl.2017.08.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The perioperative surgical home (PSH) is a patient-centered model designed to improve health, streamline the delivery of health care, and reduce the cost of care. Following the national introduction of PSH in 2014 by the ASA, adult hospitals have reported success with this model, with studies validating the benefits of PSH including reducing length of stay, lowering costs, and improving patient satisfaction. METHODS Eligible patients, ranging in age from 16-35 months of age, were identified by the pre-admission testing (PAT) registered nurses (RNs) and faculty anesthesiologists upon review of the patient history. Participation in Pediatric PSH (PPSH) was introduced to the families by the pediatric otolaryngologists. Either the patient's family or physician team could elect to decline participation in the PPSH model. On the day of surgery, the PPSH protocol included a paper checklist to ensure that all patients met eligibility standards. A standardized order-set was implemented in the electronic medical record (EMR) for pre-operative and post-operative nursing instructions and eligible medications. Patients received at least 3 hours of postoperative monitoring prior to discharge home to address postoperative issues. Prior to discharge, caregivers watched a standard teaching video, available on YouTube, which was developed in conjunction with the hospital educational and technical support staff. An attending anesthesiologist made a postoperative followup phone call on the evening of surgery to ensure no untoward events were experienced by the patient as well as elicit caregiver feedback concerning the discharge process. The protocol was discontinued if at any time family members, physicians, or nurses were uncomfortable with completing the protocol or felt that the patient did not meet discharge criteria. RESULTS One hundred sixty-six patients were evaluated for PPSH inclusion. Forty patients were excluded (23 did not meet inclusion criteria, 5 had viral upper respiratory infections, and 10 for other non specified reasons such as tonsillectomy added, sibling with surgery, and incorrect documentation). Therefore, a total of 126 were eligible for PPSH (male/female = 69/57; age 22 ± 4 months). The comparison group included 1,029 children (male/female = 645/384; age 22 ± 7 months of age) undergoing adenoidectomy who were not evaluated for PPSH inclusion. Of the 126 PPSH participants included in the analysis, 27 were excluded at some point during the pathway. Nine cases experienced oxygen desaturation, laryngospasm, or required supplemental oxygen. Noncompliance with the protocol was noted in 5 cases, parental concerns were noted in 17 cases, and there were concerns from the pediatric anesthesiologist or otolaryngologist in 5 cases. In the comparison group, hospital length of stay was significantly longer than in the PSH group (p<0.001), with 524 (51%) patients discharged on the day of service compared to 99 (79%) in the PSH group. No major morbidity or mortality occurred. There was no difference between the two groups in return to the emergency department (ED) visits within 30 days (PSH: 7/126, 6%; control: 59/1,029, 6%; p=0.935). Within 14 days of the procedure, 4 PPSH patients visited urgent care or a primary care physician; 4 visited the ED; and 1 was readmitted to the hospital. Twenty families contacted the otorhinolaryngology triage phone line primarily related to pain and fever. CONCLUSION We present our experience and success in developing a PPSH for patients, ranging in age from 16 to 35 months of age, undergoing adenoidectomy either alone or with tympanostomy tube insertion by protocolizing care, collaborating among care providers, and educating families. With this process in place, a significant percentage of these patients who were previously admitted were discharged home the same day of surgery.
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Affiliation(s)
- Vidya T Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University, Columbus, OH, USA.
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joshua Uffman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Arlyne K Thung
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Candice Burrier
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Kris R Jatana
- Department of Otolaryngology, Nationwide Children's Hospital and Wexner Medical Center at Ohio State University, Columbus, OH, USA
| | - Charles Elmaraghy
- Department of Otolaryngology, Nationwide Children's Hospital and Wexner Medical Center at Ohio State University, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
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Consideraciones en el paciente pediátrico con síndrome de apnea/hipopnea obstructiva del sueño (SAHOS): desde la fisiopatología al perioperatorio. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Considerations in pediatric patients with obstructive sleep apnea/hypopnea syndrome (OSAHS): From physiopathology to the perioperative period. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Considerations in pediatric patients with obstructive sleep apnea/hypopnea syndrome (OSAHS): From physiopathology to the perioperative period☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201707000-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Pediatric tonsillectomy is a resource-intensive procedure: a study of Canadian health administrative data. Can J Anaesth 2017; 64:724-735. [DOI: 10.1007/s12630-017-0888-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/21/2016] [Accepted: 04/13/2017] [Indexed: 01/01/2023] Open
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Subramanyam R, Fleck R, McAuliffe J, Radhakrishnan R, Jung D, Patino M, Mahmoud M. Morfologia das vias aéreas superiores em pacientes com síndrome de Down sob sedação com dexmedetomidina. Braz J Anesthesiol 2016; 66:388-94. [DOI: 10.1016/j.bjan.2015.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/26/2014] [Indexed: 11/27/2022] Open
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Tait AR, Bickham R, O'Brien LM, Quinlan M, Voepel-Lewis T. The STBUR questionnaire for identifying children at risk for sleep-disordered breathing and postoperative opioid-related adverse events. Paediatr Anaesth 2016; 26:759-66. [PMID: 27219118 DOI: 10.1111/pan.12934] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Children with symptoms of sleep-disordered breathing (SDB) appear to be at risk for perioperative respiratory events (PRAE). Furthermore, these children may be more sensitive to the respiratory-depressant effects of opioids compared with children without SDB. AIMS The aim of this prospective observational study was to confirm that otherwise healthy children with symptoms of SDB are at greater risk for PRAE compared with children with no symptoms and to determine if these children are also at increased risk for postoperative opioid-related adverse events (ORAE). METHODS Six hundred and seventy-eight parents of children scheduled for surgery completed the Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire preoperatively. Data regarding the incidence of PRAE were collected prospectively. Postoperative pulse oximetry desaturation alarm events were downloaded from the institutional secondary alarm notification system. RESULTS Children with symptoms of SDB per STBUR (≥3 symptoms) had a two-fold increased likelihood of PRAE compared with children without SDB (52.8% vs 27.9% respectively, LR(+) = 2.00, 95% CI = 1.60-2.49, P = 0.0001). A subset analysis of children undergoing airway procedures requiring hospital admittance (n = 179) showed that those with SDB were given the same postoperative opioid doses as children without SDB. However, children with SDB symptoms generated a greater number of postoperative oxygen desaturation alarms (14.14 ± 29.3 vs 7.12 ± 13.2, mean difference = 7.02, 95% CI = 0.39-13.64, P = 0.038) and more frequently required escalation of care (15.3% vs 7.1%, LR(+) = 1.67, 95% CI = 1.22-2.16, P = 0.001) compared with children with no SDB symptoms. CONCLUSIONS Children presenting for surgery with SDB symptoms are at increased risk for PRAE. Children undergoing airway-related procedures also appear to be at increased risk for ORAE. Furthermore, regardless of the preoperative assessment of risk using the STBUR questionnaire, children received the same doses of opioids postoperatively. Given the increased incidence of postoperative oxygen desaturations among children with SDB symptoms, it would seem prudent to consider titration of opioid doses according to identified risk.
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Affiliation(s)
- Alan R Tait
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Rebecca Bickham
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA.,The University of Michigan Medical School, University of Michigan Health System, Ann Arbor, MI, USA
| | - Louise M O'Brien
- Department of Neurology, University of Michigan Health System, Ann Arbor, MI, USA.,Department of Oral/Maxillofacial Surgery, University of Michigan Health System, Ann Arbor, MI, USA.,The Michael S. Aldridge Sleep Disorders Center, University of Michigan Health System, Ann Arbor, MI, USA
| | - Megan Quinlan
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA.,The University of Michigan Medical School, University of Michigan Health System, Ann Arbor, MI, USA
| | - Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
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Schymik FA, Lavoie Smith EM, Voepel-Lewis T. Parental Analgesic Knowledge and Decision Making for Children With and Without Obstructive Sleep Apnea After Tonsillectomy and Adenoidectomy. Pain Manag Nurs 2015; 16:881-9. [DOI: 10.1016/j.pmn.2015.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/03/2015] [Indexed: 02/06/2023]
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Subramanyam R, Fleck R, McAuliffe J, Radhakrishnan R, Jung D, Patino M, Mahmoud M. Upper airway morphology in Down Syndrome patients under dexmedetomidine sedation. Braz J Anesthesiol 2015; 66:388-94. [PMID: 27343789 DOI: 10.1016/j.bjane.2014.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/26/2014] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with Down Syndrome are vulnerable to significant upper airway obstruction due to relative macroglossia and dynamic airway collapse. The objective of this study was to compare the upper airway dimensions of children with Down Syndrome and obstructive sleep apnea with normal airway under dexmedetomidine sedation. METHODS IRB approval was obtained. In this retrospective study, clinically indicated dynamic sagittal midline magnetic resonance images of the upper airway were obtained under low (1mcg/kg/h) and high (3mcg/kg/h) dose dexmedetomidine. Airway anteroposterior diameters and sectional areas were measured as minimum and maximum dimensions by two independent observers at soft palate (nasopharyngeal airway) and at base of the tongue (retroglossal airway). RESULTS AND CONCLUSIONS Minimum anteroposterior diameter and minimum sectional area at nasopharynx and retroglossal airway were significantly reduced in Down Syndrome compared to normal airway at both low and high dose dexmedetomidine. However, there were no significant differences between low and high dose dexmedetomidine in both Down Syndrome and normal airway. The mean apnea hypopnea index in Down Syndrome was 16±11. Under dexmedetomidine sedation, children with Down Syndrome and obstructive sleep apnea when compared to normal airway children show significant reductions in airway dimensions most pronounced at the narrowest points in the nasopharyngeal and retroglossal airways.
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Affiliation(s)
- Rajeev Subramanyam
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, OH, USA.
| | - Robert Fleck
- Department of Radiology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - John McAuliffe
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Rupa Radhakrishnan
- Department of Radiology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Dorothy Jung
- Department of Radiology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Mario Patino
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Mohamed Mahmoud
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, OH, USA
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Tait AR, Voepel-Lewis T. Sleep-Disordered Breathing--Not Just for Grownups Anymore. J Perianesth Nurs 2015; 30:566-570. [PMID: 26596395 DOI: 10.1016/j.jopan.2015.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 09/12/2015] [Indexed: 10/22/2022]
Abstract
Previous research on SDB in children has focus edprimarily on OSA, whereas there is an increasing body of evidence to suggest that children with a spectrum of SDB symptoms may be at risk for perioperative and postoperative adverse events. To this end, it is imperative that these children are identified before surgery so that anesthesia and postoperative pain management plans can be optimized to mitigate risk. Although PSG remains the gold standard as a means to screen for SDB preoperatively,there are now clinically valid tools that can be used as part of the preanesthetic interview to identify children at risk. However, although recent work suggests that implementation of such screening tools may be important in identifying at-risk children and reducing perioperative adverse events through changes in anesthetic management, there is still much to be done with respect to changing the culture of standard postoperative opioid dosing. Perianesthesia nurses are thus in a unique position to help encourage a culture in which SDB in children is recognized asa significant risk for both perioperative and potentially deadly postoperative sequelae.
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Dalesio NM, McMichael DH, Benke JR, Owens S, Carson KA, Schwengel DA, Schwartz AR, Ishman SL. Are nocturnal hypoxemia and hypercapnia associated with desaturation immediately after adenotonsillectomy? Paediatr Anaesth 2015; 25:778-785. [PMID: 26149770 PMCID: PMC4944843 DOI: 10.1111/pan.12647] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children who undergo adenotonsillectomy for sleep-disordered breathing frequently have postoperative oxygen desaturations. Nocturnal hypoxia has been shown to predict postoperative respiratory complications; however, other gas exchange abnormalities detected on polysomnography (PSG) have not been evaluated. AIM We sought to determine whether hypercapnia seen on preoperative nocturnal PSG can predict postoperative hypoxemia. METHODS We conducted a retrospective review of 319 children who underwent polysomnography before adenotonsillectomy. Saturation levels were recorded for at least 2 h postoperatively, and the primary outcome was desaturation (<90%). RESULTS The median patient age was 5 years (range, 5 months-17 years). Patients who desaturated postoperatively had higher median peak endtidal CO2 (EtCO2 ) levels (55.5 vs 52 mmHg; P = 0.02), lower saturation nadirs (80.5% vs 88%; P = 0.048), and were younger (2 vs 6 years; P < 0.001) than those without desaturation. Age was significantly correlated with peak EtCO2 (r = -0.16), respiratory disturbance index (RDI; r = -0.23), and oxygen saturation nadir (r = 0.25; all P < 0.01). In unadjusted analysis, age <3 years compared to ≥9 years (odds ratio [OR] = 10.09; 95% confidence interval [CI] = 2.13-96.26), peak EtCO2 > 55 mmHg (OR = 3.38; 95% CI = 1.21-9.47), and RDI ≥ 10 (OR = 2.89; 95% CI = 1.05-8.42) were associated with increased odds of desaturation. Multivariable logistic regression on age, race, sex, peak EtCO2 , RDI, opioid use, and saturation nadir showed that only age was significantly associated with postoperative desaturation. Patients 0-2 years old were 10.43 (95% CI = 1.89-110.9) times more likely to have desaturation than patients 9-17 years old. CONCLUSION Patients <3 years of age are most likely to have postoperative hypoxemia after adenotonsillectomy. Gas exchange abnormalities did not correlate with postoperative desaturations, although age and peak EtCO2 did strongly correlate.
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Affiliation(s)
- Nicholas M. Dalesio
- Johns Hopkins School of Medicine, Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology/Critical Care Medicine, Baltimore, USA,Johns Hopkins School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA
| | - D. Hale McMichael
- Johns Hopkins School of Medicine, Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology/Critical Care Medicine, Baltimore, USA
| | - James R. Benke
- Johns Hopkins School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, USA
| | - Sean Owens
- Johns Hopkins School of Medicine, Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology/Critical Care Medicine, Baltimore, USA
| | - Kathryn A. Carson
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, USA
| | - Deborah A. Schwengel
- Johns Hopkins School of Medicine, Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology/Critical Care Medicine, Baltimore, USA
| | - Alan R. Schwartz
- Johns Hopkins School of Medicine, Department of Internal Medicine-Division of Pulmonary and Critical Care Medicine, Baltimore, USA
| | - Stacey L. Ishman
- Cincinnati Children’s Hospital Medical Center, Division of Otolaryngology and Division of Pulmonary Medicine, Cincinnati, USA; University of Cincinnati School of Medicine, Department of Otolaryngology – Head & Neck Surgery and Department of Pediatrics, Cincinnati, USA
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Côté V, Ruiz AG, Perkins J, Sillau S, Friedman NR. Characteristics of children under 2 years of age undergoing tonsillectomy for upper airway obstruction. Int J Pediatr Otorhinolaryngol 2015; 79:903-908. [PMID: 25912628 DOI: 10.1016/j.ijporl.2015.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 04/02/2015] [Accepted: 04/04/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION To study characteristics of children less than 2 years who underwent a tonsillectomy for sleep disordered breathing (SDB) or obstructive sleep apnea (OSA) to assess for factors associated with requesting a preoperative polysomnogram (PSG) and to identify predictors of upper airway obstruction in this group. MATERIALS AND METHODS A retrospective chart review of children under 2 years who underwent a tonsillectomy over a 7-year period at a tertiary care pediatric hospital was undertaken. Patient demographics, characteristics and polysomnography results, when applicable, were collected. In order to determine if the gathered demographics of our cohort differed from the non-surgical population, we compared our data with available Colorado data for each variable. Children were stratified by OSA severity using their obstructive apnea-hypopnea index (OAHI). RESULTS 197 (2.2%) of 9038 patients who underwent tonsillectomy for SDB or OSA were ≤ 24 months. The proportions of male, African-American, Hispanic, obese, underweight, premature, syndromic and daycare patients in our cohort were significantly different than in the general population. In a multivariate model, the odds of African-Americans having severe OSA were 12.5 times greater than the odds of Caucasians. The odds of patients with syndromes or craniofacial anomalies were 11 times greater (p < 0.0001), and the odds of patients in daycare were 2.2 times lower (p = 0.04) of undergoing a PSG before tonsillectomy. Weight did not influence polysomnogram requests. CONCLUSIONS In children under 2 years, ethnicity seems to be a predictor of OSA severity. African-American, prematurity, daycare and Down syndrome patients were significantly more represented in our study population. PSG is more likely to be requested for syndromic children.
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Affiliation(s)
- Valérie Côté
- Department of Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Amanda G Ruiz
- Department of Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Jonathan Perkins
- Department of Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States
| | - Stefan Sillau
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO, United States
| | - Norman R Friedman
- Department of Otolaryngology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States.
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Murto K, Lamontagne C, McFaul C, MacCormick J, Ramakko KA, Aglipay M, Rosen D, Vaillancourt R. Celecoxib pharmacogenetics and pediatric adenotonsillectomy: a double-blinded randomized controlled study. Can J Anaesth 2015; 62:785-97. [PMID: 25846344 PMCID: PMC4457100 DOI: 10.1007/s12630-015-0376-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 03/26/2015] [Indexed: 12/16/2022] Open
Abstract
Background Pediatric adenotonsillectomy (A&T) is associated with prolonged pain and functional limitation. Celecoxib is an effective analgesic in adult surgery patients; however, its analgesic efficacy on pain and functional recovery in pediatric A&T patients is unknown. Methods During 2009-2012, children (age 2-18 yr) scheduled for elective A&T were enrolled in a single-centre double-blind randomized controlled trial. Study participants received either oral placebo or celecoxib 6 mg·kg−1 preoperatively, followed by 3 mg·kg−1 twice daily for five doses. The primary outcome was the mean “worst 24-hr pain” scores during postoperative days (PODs) 0-2 on a 100-mm visual analogue scale (VAS). Secondary outcomes for PODs 0-7 included co-analgesic consumption, adverse events, and functional recovery. The impact of the CYP2C9*3 allele – associated with reduced celecoxib hepatic metabolism – on recovery was considered. Results Of the 282 children enrolled, 195 (celecoxib = 101, placebo = 94) were included in the primary outcome analysis. While on treatment, children receiving celecoxib experienced a modest reduction in the average pain experienced over PODs 0-2 (7 mm on a VAS; 95% confidence interval [CI]: 0.3 to 14; P = 0.04) and a “clinically significant” reduction (≥ 10 mm on a VAS; P ≤ 0.01) on PODs 0 and 1. During PODs 0-2, the mean acetaminophen consumption was lower in the celecoxib group vs the placebo group (78 mg·kg−1; 95% CI: 68 to 89 vs 97 mg·kg−1; 95% CI: 85 to 109, respectively; P = 0.03). No differences in adverse events, functional recovery, or satisfaction were observed by POD 7. The CYP2C9*3 allele was associated with less pain and improved functional recovery. Conclusions A three-day course of oral celecoxib reduces early pain and co-analgesic consumption; however, an increase in dose, dose frequency, and duration of dose may be required for sustained pain relief in the pediatric setting. The CYP2C9*3 allele may influence recovery. This trial was registered at: ClinicalTrials.gov: NCT00849966. Electronic supplementary material The online version of this article (doi:10.1007/s12630-015-0376-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kimmo Murto
- Department of Anesthesiology, Children's Hospital of Eastern Ontario (CHEO), University of Ottawa, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Canada,
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Park CS, Guilleminault C, Park HJ, Cho JH, Lee HK, Son HL, Hwang SH. Correlation of salivary alpha amylase level and adenotonsillar hypertrophy with sleep disordered breathing in pediatric subjects. J Clin Sleep Med 2015; 10:559-66. [PMID: 24812542 DOI: 10.5664/jcsm.3712] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea syndrome (OSAS) and sleep disordered breathing (SDB) can affect the sympathetic adrenomedullary system (SAM). As a biomarker of SAM activity, salivary α-amylase (sAA) in pediatric subjects was evaluated whether it has any correlation with polysomnographic (PSG) parameters related to SDB. METHODS Sixty-seven children who attended our clinic during 1 year were enrolled prospectively and underwent clinical examinations and in-lab polysomnography. The sAA was measured at 2 points--at night before PSG and in the early morning after PSG. RESULTS Subjects were divided into control (n = 26, apneahypopnea index [AHI] < 1) and OSAS (n = 41, AHI ≥ 1) groups. The OSAS group was subdivided according to AHI (mild-moderate, 1 ≤ AHI < 10; severe, AHI ≥ 10). The sAA subtraction and ratio (p = 0.014 and p < 0.001, respectively) were significantly higher in severe OSAS than in the mild-moderate and control groups. Although oxygen desaturation index (ODI) and AHI were significantly associated with sAA, sAA in the OSAS group was not related to lowest oxygen saturation or adenotonsillar hypertrophy. CONCLUSION sAA was well related to polysomnographic (PSG) parameters related to SDB, such as AHI and ODI. Therefore, screening test for sAA in children suspected to have SBD may help to identify OSAS patients from control.
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Affiliation(s)
- Chan-Soon Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Suwon St. Vincent's Hospital
| | | | - Hong-Jin Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Suwon St. Vincent's Hospital
| | | | - Heung-Ku Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Suwon St. Vincent's Hospital
| | - Hye-Lim Son
- Department of Otorhinolaryngology-Head and Neck Surgery, Suwon St. Vincent's Hospital
| | - Se-Hwan Hwang
- Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Republic of Korea
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Chan CCK, Au CT, Lam HS, Lee DLY, Wing YK, Li AM. Intranasal corticosteroids for mild childhood obstructive sleep apnea--a randomized, placebo-controlled study. Sleep Med 2015; 16:358-63. [PMID: 25650159 DOI: 10.1016/j.sleep.2014.10.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 10/10/2014] [Accepted: 10/12/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of non-surgical treatment for childhood obstructive sleep apnea (OSA) is gaining popularity, especially in children with mild disease. OBJECTIVE To test the hypothesis that intranasal corticosteroids reduce disease severity in children with mild OSA. STUDY DESIGN A randomized, double-blinded, placebo-controlled trial of intranasal mometasone furoate (MF) versus placebo in children aged 6 to 18 years with mild OSA. The primary outcome was the change from baseline obstructive apnea hypopnea index (OAHI), as documented by overnight polysomnography, after four months of treatment. RESULTS Sixty-two children were recruited but 12 dropped out. This left 24 and 26 children for final analysis in the MF and placebo group, respectively. The OAHI and oxygen desaturation index (ODI) improved significantly in the MF group only. The OAHI decreased from 2.7 ± 0.2 to 1.7 ± 0.3 in the MF group, but increased from 2.5 ± 0.2 to 2.9 ± 0.6 in the placebo group (p = 0.039). The mean changes in ODI in the MF group and placebo group were -0.6 ± 0.5 and +0.7 ± 0.4, respectively (p = 0.037). CONCLUSION Four months of treatment with intranasal mometasone furoate effectively reduces the severity of mild OSA in children.
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Affiliation(s)
- Ching Ching Kate Chan
- Department of Pediatrics, Otorhinolaryngology - Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
| | - Chun T Au
- Department of Pediatrics, Otorhinolaryngology - Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Hugh S Lam
- Department of Pediatrics, Otorhinolaryngology - Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Dennis L Y Lee
- Department of Pediatrics, Otorhinolaryngology - Head and Neck Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Yun K Wing
- Department of Psychiatry, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Albert M Li
- Department of Psychiatry, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Confronting the challenges of effective pain management in children following tonsillectomy. Int J Pediatr Otorhinolaryngol 2014; 78:1813-27. [PMID: 25241379 DOI: 10.1016/j.ijporl.2014.08.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/11/2014] [Indexed: 12/29/2022]
Abstract
Tonsillectomy is an extremely common surgical procedure associated with significant morbidity and mortality. The post-operative challenges include: respiratory complications, post-tonsillectomy hemorrhage, nausea, vomiting and significant pain. The present model of care demands that most of these children are managed in an ambulatory setting. The recent Federal Drug Agency (FDA) warning contraindicating the use of codeine after tonsillectomy in children represents a significant change of practice for many pediatric otolaryngological surgeons. This introduces a number of other safety concerns when deciding on a safe alternative to codeine, especially since most tonsillectomy patients are managed by lay primary caregiver's at home. This review outlines the safety issues and proposes, based on currently available evidence, a preventative multi-modal strategy to manage pain, nausea and vomiting without increasing the risk of post-tonsillectomy bleeding.
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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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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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Affiliation(s)
- L Strauss
- Department of Anaesthesia, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand
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Şanlı M, Toplu Y, Özgül Ü, Kayhan GE, Gülhaş N. Anaesthetic Management in Obstructive Sleep Apnoea Syndrome for Adenotonsillectomy. Turk J Anaesthesiol Reanim 2014; 42:230-2. [PMID: 27366426 DOI: 10.5152/tjar.2014.45822] [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: 08/14/2013] [Accepted: 10/08/2013] [Indexed: 11/22/2022] Open
Abstract
The anaesthetic management of adenotonsillectomy in children with obstructive sleep apnoea syndrome is characteristic due to respiratory and cardiac side effects. A detailed physical examination in the preoperative period should be performed, including children's respiratory and cardiac systems. If they have an active infection, surgery should be postponed until the end of medical treatment. Preparation for difficult airway management should be done in the preoperative period. In this case, we presented a report of two children who had obstructive sleep apnoea syndrome, with airway management performed at the right lateral position to prevent the pharyngeal collapse and rapid sequence intubation performed using a short-acting muscle relaxant.
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Affiliation(s)
- Mukadder Şanlı
- Department Anaesthesiology and Reanimation, İnönü University Faculty of Medicine, Malatya, Turkey
| | - Yüksel Toplu
- Department of Ear, Nose, Throat, İnönü University Faculty of Medicine, Malatya, Turkey
| | - Ülkü Özgül
- Department Anaesthesiology and Reanimation, İnönü University Faculty of Medicine, Malatya, Turkey
| | - Gülay Erdoğan Kayhan
- Department Anaesthesiology and Reanimation, İnönü University Faculty of Medicine, Malatya, Turkey
| | - Nurçin Gülhaş
- Department Anaesthesiology and Reanimation, İnönü University Faculty of Medicine, Malatya, Turkey
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Cladis F, Kumar A, Grunwaldt L, Otteson T, Ford M, Losee JE. Pierre Robin Sequence. Anesth Analg 2014; 119:400-412. [DOI: 10.1213/ane.0000000000000301] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nafiu OO, Prasad Y, Chimbira WT. Association of childhood high body mass index and sleep disordered breathing with perioperative laryngospasm. Int J Pediatr Otorhinolaryngol 2013; 77:2044-8. [PMID: 24182867 DOI: 10.1016/j.ijporl.2013.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/30/2013] [Accepted: 10/03/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Childhood high body mass index (BMI) and sleep disordered breathing (SDB) are increasingly prevalent and both are associated with perioperative respiratory complications. Laryngospasm is one of the more serious respiratory complications with potentially devastating consequences. It is presently unclear whether high BMI and incident SDB in children significantly amplifies the risks of perioperative laryngospasm. This study examined the hypothesis that compared to controls; children with high BMI and SDB at the time of surgery have higher rates of perioperative laryngospasm. METHODS Children (6-18 yr) who underwent elective, non-cardiac operations at a tertiary care center were the subjects of this cross-sectional study. Rates of perioperative laryngospasm were compared between normal controls and children who were overweight/obese and had clinical history of SDB at the time of surgery. Stepwise logistic regression analysis was performed to identify independent predictors of perioperative laryngospasm (dependent variable) using high BMI/SDB as the primary predictor variable. RESULTS Among 642 children, those who were overweight/obese and had incident SDB (N = 197) were younger, and had higher indexes of central adiposity. Children with high BMI and SDB had 3.8 times higher unadjusted odds of developing intraoperative laryngospasm (OR = 3.8; 95% CI = 2.1-6.9, p < 0.001). After adjusting for several relevant covariates, the following factors were found to be independent predictors of perioperative laryngospasm: high BMI + SDB, male sex and increasing neck circumference. CONCLUSION High BMI and incident SDB in children is associated with increased rates of perioperative laryngospasm. The mechanism(s) underlying this propensity to laryngospasm deserve further elucidation.
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Affiliation(s)
- Olubukola O Nafiu
- Department of Anesthesiology, Section of Pediatric Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
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Valois-Gómez T, Oofuvong M, Auer G, Coffin D, Loetwiriyakul W, Correa JA. Incidence of difficult bag-mask ventilation in children: a prospective observational study. Paediatr Anaesth 2013; 23:920-6. [PMID: 23905781 DOI: 10.1111/pan.12144] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 01/30/2013] [Accepted: 02/01/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Difficult airway (DA), including difficult bag-mask ventilation (DBMV), and difficult intubation (DI) is an important challenge for the pediatric anesthesiologist. While expected DBMV can be successfully managed with appropriate equipment and personnel, unexpected DBMV relies on the resources available and the experience of the anesthesiologist at the time of the emergency. The incidence and risk factors of unexpected DA in otherwise healthy children, including DBMV among pediatric patients are not known. The aim of this study was to expand the scientific knowledge of unexpected DBMV among pediatric patients. METHODS Patients between the ages of 0 and 8 years, undergoing elective surgery requiring bag-mask ventilation BMV and intubation at the Montreal Children's Hospital were recruited in this prospective observational study. Data on the incidence of DBMV and risk factors were collected over a 3-year period. RESULTS In a sample of 484 children, the incidence of unexpected difficult BMV was 6.6% (95% CI [4.6, 9.2]). The incidence of expected DA among the screened patients (N = 4865) was 0.5% (95% CI [0.3, 0.7]). In a logistic regression analysis, age (OR 0.98; 95%CI [0.97, 0.99]), undergoing otolaryngology (ENT) surgery (OR 2.92; 95% CI [1.08, 7.95]) and use of neuromuscular blocking agents (OR 3.49; 95%CI [1.50-8.11]) were independently associated with DBMV. The incidence of DI was 1.2%. No association between DBMV and DI was found (Fisher's exact test, P = 1.0). CONCLUSIONS This is the first published report of the incidence of unexpected DBMV among healthy pediatric patients.
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Pavone M, Cutrera R, Verrillo E, Salerno T, Soldini S, Brouillette RT. Night-to-night consistency of at-home nocturnal pulse oximetry testing for obstructive sleep apnea in children. Pediatr Pulmonol 2013; 48:754-60. [PMID: 23533148 DOI: 10.1002/ppul.22685] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 08/28/2012] [Accepted: 08/29/2012] [Indexed: 01/18/2023]
Abstract
RATIONALE At-home nocturnal pulse oximetry has a high positive predictive value (PPV) for polysomnographically-diagnosed obstructive sleep apnea (OSA) but no studies have been published testing the night-to-night consistency of at-home nocturnal pulse oximetry for the evaluation of suspected OSA in children. We therefore determined the night-to-night consistency of nocturnal pulse oximetry as a diagnostic test for OSA in children. METHODS We prospectively studied 148 children (96 male) aged 4.9 ± 2.4 (1.2-11.8) years, referred for suspected OSA. To evaluate night-to-night consistency, we compared an oximetry analysis method, the McGill Oximetry Score (MOS), from two consecutive at-home nocturnal pulse oximetry recordings. RESULTS Pulse oximetry metrics were similar on the two nights. The MOS on the two nights showed excellent night-to-night consistency when analyzed as positive for OSA versus inconclusive, 143/148 (Spearman's correlation coefficient = 0.90). A more detailed analysis using four categories (MOS 1, 2, 3, and 4) of OSA severity showed very good night-to-night agreement, 133/148 (Spearman's correlation coefficient = 0.91). Variability was increased in children younger than 4 years of age compared to older children. CONCLUSIONS Night-to-night consistency of nocturnal pulse oximetry as a diagnostic test for OSA showed excellent agreement. Night-to-night consistency of pulse oximetry, as analyzed by the MOS, for diagnosis and severity evaluation further validates this abbreviated testing method for pediatric OSA. Polysomnography (PSG) is required to rule in or rule out OSA in children if a single night oximetry testing is inconclusive.
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Affiliation(s)
- Martino Pavone
- Respiratory Unit, Department of Pediatrics, Bambino Gesù Children's Hospital, Piazza S. Onofrio, 00165 Rome, Italy.
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Tait AR, Voepel-Lewis T, Christensen R, O’Brien LM. The STBUR questionnaire for predicting perioperative respiratory adverse events in children at risk for sleep-disordered breathing. Paediatr Anaesth 2013; 23:510-6. [PMID: 23551934 PMCID: PMC3648590 DOI: 10.1111/pan.12155] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND In the absence of formal polysomnography (PSG), many children with symptoms of sleep-disordered breathing (SDB) go unrecognized and thus may be at risk for perioperative respiratory adverse events (PRAE). OBJECTIVES To develop a simple practical tool to identify children with symptoms consistent with SDB who may be at risk for PRAE. METHODS Three-hundred and thirty-seven parents of children scheduled for surgery completed the Sleep-Related Breathing Disorder (SRBD) questionnaire. Data regarding the incidence and severity of PRAE including airway obstruction and laryngospasm, were collected prospectively. RESULTS Thirty-two (9.5%) children had a confirmed diagnosis of SDB by PSG and 90 (26.7%) had symptoms consistent with SDB based on the SRBD questionnaire. Principal component analysis identified five symptoms from the SRBD questionnaire that were strongly predictive of PRAE and which were incorporated into the STBUR tool (Snoring, Trouble Breathing, Un-Refreshed). The likelihood of PRAE was increased by threefold (positive likelihood ratio 3.06 [1.64-5.96] in the presence of any 3 STBUR symptoms and by tenfold when all five symptoms were present (9.74 [1.35-201.8]). In comparison, the likelihood of PRAE based on a PSG-confirmed diagnosis of SDB was 2.63 (1.17-6.23). CONCLUSIONS Children presenting for surgery with symptoms consistent with SDB may be at risk for PRAE. It is important therefore that anesthesia providers identify these individuals prior to surgery to avoid potential complications. The STBUR questionnaire appears promising as a simple, clinically useful tool for identifying children at risk for PRAE. Further studies to validate the STBUR questionnaire as a diagnostic tool may be warranted.
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Affiliation(s)
- Alan R. Tait
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, U.S.A.
,Center for Behavioral and Decision Sciences in Medicine, University of Michigan Health System, Ann Arbor, U.S.A
| | - Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, U.S.A
| | - Robert Christensen
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, U.S.A
| | - Louise M. O’Brien
- Department of Neurology, University of Michigan Health System, Ann Arbor, U.S.A.
,Department of Oral/Maxillofacial Surgery, University of Michigan Health System, Ann Arbor, U.S.A.
,Michael S. Aldridge Sleep Disorders Center, University of Michigan Health System, Ann Arbor, U.S.A
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Abback PS, Ben Sallah T, Hilly J, Skhiri A, Silins V, Brasher C, François M, Van Den Abeele T, Wood C, Nivoche Y, Dahmani S. [Opioid-sparing effect of ketamine during tonsillectomy in children]. ACTA ACUST UNITED AC 2013; 32:387-91. [PMID: 23623534 DOI: 10.1016/j.annfar.2013.02.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 02/18/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In the adult population, Ketamine is currently used as an antihyperalgesic and opioid-sparing agent during the perioperative period. However, for doses of ketamine up to 0.5mg/kg, these effects have not been found in pediatric population. The aim of the present study was to evaluate the efficacy of a preoperative bolus of 1mg/kg of ketamine on postoperative pain intensity and morphine consumption in children undergoing tonsillectomy. METHODS We have undertaken a retrospective comparison of 60 consecutive children operated for tonsillectomy in our institution before (first 30 patients) and after (last 30 patients) the introduction of a preoperative bolus of 1mg/kg of ketamine. Data collected were: age, ASA score, dose of intraoperative sufentanil, OPS score during PACU stay and the first postoperative day, morphine consumption during PACU stay and the first postoperative day, psychodysleptic manifestations, pain at first solid oral intake and postoperative respiratory complications or haemorrhage. RESULTS No difference was found between the two groups in terms of demographic characteristics. Perioperative doses of sufentanil, postoperative opioid consumption or pain score in PACU or during 24hours were similar between the two groups. The two groups did not differ in terms of pain at first oral intake, or other adverse effects. CONCLUSION These results suggest that 1mg/kg of ketamine administered right after anaesthesia induction in children undergoing tonsillectomy did not result in an opioid sparing effect.
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Affiliation(s)
- P-S Abback
- Département d'anesthésie et réanimation, faculté de médecine Denis-Diderot-Paris-VII, PRES Paris-Sorbonne, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92110 Clichy-la-Garenne, France.
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