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Brennan MP, Webber AM, Patel CV, Chin WA, Butz SF, Rajan N. Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg 2024:00000539-990000000-00799. [PMID: 38517763 DOI: 10.1213/ane.0000000000006645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.
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Affiliation(s)
- Marjorie P Brennan
- From the Department of Anesthesiology, Pain and Perioperative Medicine, The George Washington University School of Medicine, Children's National Hospital, Washington, DC
| | - Audra M Webber
- University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Chhaya V Patel
- Department of Anesthesiology and Pediatrics, Emory School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Wanda A Chin
- Department of Anesthesiology and Perioperative Medicine, New York University Grossman School of Medicine, NYU Lagone Health, New York, New York
| | - Steven F Butz
- Department of Anesthesiology, Medical College of Wisconsin, Children's Wisconsin Surgicenter
| | - Niraja Rajan
- Department of Anesthesiology, Penn State Milton S Hershey Medical Center, Hershey Outpatient Surgery Center, Hershey, Pennsylvania
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2
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Lopes Vieira J, Miskovic A, Abel F. Interpretation of sleep studies and perioperative considerations in children with sleep-disordered breathing. BJA Educ 2023; 23:448-454. [PMID: 37876762 PMCID: PMC10591125 DOI: 10.1016/j.bjae.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 10/26/2023] Open
Affiliation(s)
| | | | - F. Abel
- Great Ormond Street Hospital, London, UK
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3
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Gray GM, Ahumada LM, Rehman MA, Varughese A, Fernandez AM, Fackler J, Yates HM, Habre W, Disma N, Lonsdale H. A machine-learning approach for decision support and risk stratification of pediatric perioperative patients based on the APRICOT dataset. Paediatr Anaesth 2023; 33:710-719. [PMID: 37211981 DOI: 10.1111/pan.14694] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Pediatric anesthesia has evolved to a high level of patient safety, yet a small chance remains for serious perioperative complications, even in those traditionally considered at low risk. In practice, prediction of at-risk patients currently relies on the American Society of Anesthesiologists Physical Status (ASA-PS) score, despite reported inconsistencies with this method. AIMS The goal of this study was to develop predictive models that can classify children as low risk for anesthesia at the time of surgical booking and after anesthetic assessment on the procedure day. METHODS Our dataset was derived from APRICOT, a prospective observational cohort study conducted by 261 European institutions in 2014 and 2015. We included only the first procedure, ASA-PS classification I to III, and perioperative adverse events not classified as drug errors, reducing the total number of records to 30 325 with an adverse event rate of 4.43%. From this dataset, a stratified train:test split of 70:30 was used to develop predictive machine learning algorithms that could identify children in ASA-PS class I to III at low risk for severe perioperative critical events that included respiratory, cardiac, allergic, and neurological complications. RESULTS Our selected models achieved accuracies of >0.9, areas under the receiver operating curve of 0.6-0.7, and negative predictive values >95%. Gradient boosting models were the best performing for both the booking phase and the day-of-surgery phase. CONCLUSIONS This work demonstrates that prediction of patients at low risk of critical PAEs can be made on an individual, rather than population-based, level by using machine learning. Our approach yielded two models that accommodate wide clinical variability and, with further development, are potentially generalizable to many surgical centers.
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Affiliation(s)
- Geoffrey M Gray
- Center for Pediatric Data Science and Analytics Methodology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Luis M Ahumada
- Center for Pediatric Data Science and Analytics Methodology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Mohamed A Rehman
- Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Anna Varughese
- Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Allison M Fernandez
- Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - James Fackler
- Department of Anesthesia, Division of Pediatric Anesthesia, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Hannah M Yates
- Department of Anesthesia, Pain and Perioperative Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Walid Habre
- Department of Anaesthesia, Pharmacology and Intensive Care, University Hospitals of Geneva, Switzerland
| | - Nicola Disma
- Unit for Research & Innovation, Department of Anesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Hannah Lonsdale
- Department of Anesthesia, Division of Pediatric Anesthesia, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Lima LACN, Otis A, Balram S, Giasson AB, Carnevale FA, Frigon C, Brown KA. Parents' perspective on recovery at home following adenotonsillectomy: a prospective single-centre qualitative analysis. Can J Anaesth 2023; 70:1202-1215. [PMID: 37160822 DOI: 10.1007/s12630-023-02479-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 11/14/2022] [Accepted: 11/15/2022] [Indexed: 05/11/2023] Open
Abstract
PURPOSE In North America, pediatric adenotonsillectomy (TA) is conducted as an ambulatory procedure, thus shifting the burden of postoperative care to parents. The purpose of this study was to describe this parental experience. METHODS We conducted a prospective single-centre qualitative study, recruiting the families of children (n = 317) undergoing elective TA in 2018. Parents were invited to submit written comments to two open-ended questions. We coded the comments from 144 parents in a grounded theory analysis and report representative exemplars. Themes and subthemes for the problems encountered, and strategies employed by parents, were developed. We then coded and classified factors that helped/hindered parents and developed models of the experience. RESULTS Some parents felt ill-prepared for the severity and duration of pain. Specific findings included a lack of strategies to manage pain at night, refusals, and night terrors. Parents identified the use of pain scales, pain diaries, and liaison with the research team as helpful supports at home. Inconsistent messaging was a barrier. The odynophagia associated with elixirs of acetaminophen and ibuprofen was a barrier to achieving analgesia. CONCLUSIONS The findings from this qualitative analysis provide insight into the challenges faced by parents when caring for their children at home following TA; these challenges included difficulties managing physical needs and pain. The analysis suggests that educational content should be standardized and include the use of pain scales and diaries, and both pharmacologic and nonpharmacologic strategies. Development of support at home, including a practicable liaison with health care providers, seems to be warranted. STUDY REGISTRATION ClinicalTrials.gov (NCT03378830); registered 20 December 2017.
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Affiliation(s)
- Laura A C N Lima
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Annik Otis
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Sharmila Balram
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Annick Bérard Giasson
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | | | - Chantal Frigon
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Karen A Brown
- Department of Anesthesia, McGill University Health Centre, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada.
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Willer BL, Petkus H, Manupipatpong K, Tram N, Nafiu OO, Tobias JD, Mpody C. Association of Obstructive Sleep Apnea With Unanticipated Admission Following Nonotolaryngologic Pediatric Ambulatory Surgery. Anesth Analg 2023; Publish Ahead of Print:00000539-990000000-00595. [PMID: 37307227 DOI: 10.1213/ane.0000000000006593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Approximately 2% of ambulatory pediatric surgeries require unanticipated postoperative admission, causing parental dissatisfaction and suboptimal use of hospital resources. Obstructive sleep apnea (OSA) occurs in nearly 8% of children and is known to increase the risk of perioperative adverse events in children undergoing otolaryngologic procedures (eg, tonsillectomy). However, whether OSA is also a risk for unanticipated admission after nonotolaryngologic surgery is unknown. The objectives of this study were to determine the association of OSA with unanticipated admission after pediatric nonotolaryngologic ambulatory surgery and to explore trends in the prevalence of OSA in children undergoing nonotolaryngologic ambulatory surgery. METHODS We used the Pediatric Health Information System (PHIS) Database to evaluate a retrospective cohort of children (<18 years) undergoing nonotolaryngologic surgery scheduled as ambulatory or observation status from January 1, 2010, to August 31, 2022. We used International Classification of Diseases codes to identify patients with OSA. The primary outcome was unanticipated postoperative admission lasting ≥1 day. Using logistic regression models, we estimated the odds ratio (OR) and 95% confidence intervals (CIs) for unanticipated admission comparing patients with and without OSA. We then estimated trends in the prevalence of OSA during the study period using the Cochran-Armitage test. RESULTS A total of 855,832 children <18 years underwent nonotolaryngologic surgery as ambulatory or observation status during the study period. Of these, 39,427 (4.6%) required unanticipated admission for ≥1 day, and OSA was present in 6359 (0.7%) of these patients. Among children with OSA, 9.4% required unanticipated admission, compared to 5.0% among those without. The odds of children with OSA requiring unanticipated admission were more than twice that in children without OSA (adjusted OR, 2.27; 95% CI, 1.89-2.71; P < .001). The prevalence of OSA among children undergoing nonotolaryngologic surgery as ambulatory or observation status increased from 0.4% to 1.7% between 2010 and 2022 (P trends < .001). CONCLUSIONS Children with OSA were significantly more likely to require unanticipated admission after a nonotolaryngologic surgery scheduled as ambulatory or observation status than those without OSA. These findings can inform patient selection for ambulatory surgery with the goal of decreasing unanticipated admissions, increasing patient safety and satisfaction, and optimizing health care resources related to unanticipated admission.
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Affiliation(s)
- Brittany L Willer
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Holly Petkus
- Heritage College of Osteopathic Medicine-Athens Campus and Ohio University, Athens, Ohio
| | - Katherine Manupipatpong
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Nguyen Tram
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Olubukola O Nafiu
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Joseph D Tobias
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Christian Mpody
- From the Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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Bérard-Giasson A, Brown KA, Agnihotram RV, Frigon C. Validation of the parent's postoperative pain measure with an age-appropriate reference pain scale for children 2-12 years old during a 14-day recovery after tonsillectomy: A prospective cohort study. Paediatr Anaesth 2022; 32:654-664. [PMID: 35120271 DOI: 10.1111/pan.14407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adenotonsillectomy is associated with severe postoperative pain. The parent's postoperative pain measure (PPPM), a 15-item instrument to measure a child's pain at home, has been validated with a seven-point faces scale in children 7-12 years and with the parents' global report of pain in children 2-6 years. AIMS Our primary objective was to validate the PPPM with a recommended age-appropriate pain scale in children 2-12 years after adenotonsillectomy. Our secondary objective was to reduce the PPPM components and validate this reduced PPPM. METHODS We recruited 319 children out of the 563 adenotonsillectomies performed between December 19, 2017, and December 18, 2018. Parents recorded administration of analgesics and their child's pain scores twice daily for 14 days: PPPM for all children and either the face, legs, arms, crying, consolability (FLACC) pain scale for children 2-3 years or the faces pain scale-revised (FPS-R) for children 4-12 years. In addition, parents recorded analgesics. RESULTS Among the 354 eligible children, 9% of parents declined. 252 (79%) families submitted pain diaries. The median age was 2.9 [2.5-3.3] years for FLACC (n = 114) and 5.6 [4.5-7.2] years for FPS-R (n = 138). Across the 14-day recovery period, Cronbach's alpha for PPPM was 0.77 to 0.87. Generalized linear mixed models evaluated the association between PPPM and reference pain scales after adjustment for potential confounders. Time of day and postoperative days were included as predictors in the models. PPPM was strongly associated with FLACC and FPS-R (beta coefficient = 0.4; p < 0.0001). The association decreased over time, and the reduction was more significant for FPS-R than FLACC (beta coefficient = -0.13 vs. -0.04, respectively; p < 0.0001). There was a positive association between PPPM and the use of analgesics. A reduction analysis eliminated items from the original PPPM: four for FLACC and five for FPS-R, suggesting age-related differences. The reduced PPPM instruments achieved similar associations with their respective reference pain scales (beta coefficient = 0.5; p < 0.0001). CONCLUSIONS This study extends previous work by validating the PPPM in children as young as 2 years with a recommended age-appropriate pain scale over 14-day convalescence after adenotonsillectomy. The reduced PPPM instruments differed in the two age groups. Future studies might explore these age-appropriate reduced PPPM instruments to assess pain at home following adenotonsillectomy.
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Affiliation(s)
- Annick Bérard-Giasson
- Department of Anesthesiology, McGill University Health Center, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Karen Ann Brown
- Department of Anesthesiology, McGill University Health Center, Montreal Children's Hospital, Montreal, Quebec, Canada
| | | | - Chantal Frigon
- Department of Anesthesiology, McGill University Health Center, Montreal Children's Hospital, Montreal, Quebec, Canada
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7
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Huerta J, Taleu H, Norton R, Gries H, Yun P, Lam D. Use of the Snoring, Trouble Breathing, Un-Refreshed questionnaire to predict perioperative respiratory adverse events in children. J Clin Sleep Med 2022; 18:695-701. [PMID: 34823651 PMCID: PMC8883104 DOI: 10.5664/jcsm.9582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The Snoring, Trouble Breathing, Un-Refreshed (STBUR) screening questionnaire has been validated in identifying pediatric surgical patients with symptoms of sleep-disordered breathing who may be at risk of perioperative respiratory adverse events. We sought to assess the performance of the STBUR questionnaire when adjusting for potential confounders such as patient comorbidities or surgical service. METHODS This was a retrospective cohort study of children aged 2-18 years undergoing elective procedures under general anesthesia over a 3-month period. Procedure specialties included general surgery, urology, orthopedic surgery, neurosurgery, plastic surgery, otolaryngology, dentistry, and gastroenterology. Preoperative STBUR questionnaire responses and perioperative respiratory adverse events were documented prospectively. Multivariate logistic regression was used to quantify associations between preoperative questionnaire responses, other potential risk factors (including age, sex, surgical specialty, comorbidities), and risk of perioperative respiratory adverse events. RESULTS Of 555 children, 17% had a positive STBUR screen. The prevalence of perioperative respiratory adverse events with a positive questionnaire screen was significantly greater than with a negative screen (29% vs 9%, respectively; P < .001). A positive questionnaire screen was associated with a significantly increased risk of a perioperative respiratory adverse event (adjusted odds ratio 3.47 [95% confidence interval 1.53-7.84], P = .003). CONCLUSIONS A positive screen on the STBUR questionnaire was associated with a 3.5-fold increased risk of perioperative respiratory adverse events in pediatric surgical patients. The STBUR questionnaire should be considered as a routine preoperative screening tool in children undergoing elective procedures. CITATION Huerta J, Taleu H, Norton R, Gries H, Yun P, Lam D. Use of the Snoring, Trouble Breathing, Un-Refreshed questionnaire to predict perioperative respiratory adverse events in children. J Clin Sleep Med. 2022;18(3):695-701.
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Affiliation(s)
- Javier Huerta
- Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Hannah Taleu
- Pediatric Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
| | - Rene Norton
- Nursing Professional Practice, Oregon Health and Science University, Portland, Oregon
| | - Heike Gries
- Pediatric Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
| | - Philip Yun
- Pediatric Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
| | - Derek Lam
- Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
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Can pediatric sleep questions be incorporated into a risk model to predict respiratory complications following adenotonsillectomy? Int J Pediatr Otorhinolaryngol 2022; 153:111015. [PMID: 34973525 DOI: 10.1016/j.ijporl.2021.111015] [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: 07/15/2021] [Revised: 11/02/2021] [Accepted: 12/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Adenotonsillectomy, one of the most frequent surgical procedures in children, is usually performed for sleep-disordered breathing, a disease spectrum from primary snoring to obstructive sleep apnea. Children undergoing an adenotonsillectomy may be at risk for perioperative respiratory complications, necessitating intervention or escalation of care. However, there is no effective preoperative screening or risk-stratification model for perioperative respiratory complications that incorporates not only clinical history and physical examination but also sleep question responses for children as there is for adults. OBJECTIVES The aim of this prospective observational study was to develop a risk-stratification model for perioperative respiratory complications in children undergoing an adenotonsillectomy incorporating not only clinical history and physical examination but also sleep question responses. METHODS A 25-question sleep questionnaire was prospectively administered preoperatively for 1895 children undergoing an adenotonsillectomy from November 2015 to December 2017. The primary outcome measure was overall perioperative respiratory complications, collected prospectively and defined as having at least one major or minor complication intraoperatively or postoperatively. RESULTS The incidence of overall perioperative respiratory complications was 20.4%. Preoperative factors associated with perioperative respiratory complications in the multiple regression model were age, race, preoperative tonsil size, the presence of a syndrome, and the presence of a pulmonary disease. None of the sleep questionnaire responses remained in the multivariable analysis. The area under the ROC curve for the risk stratification model incorporating sleep question responses was only 0.6114% (95% CI: 0.60, 0.67). CONCLUSION Preoperative sleep question responses may be unable to predict overall perioperative respiratory complications in children undergoing an adenotonsillectomy. A robust risk stratification model incorporating sleep question responses with clinical history and physical examination was unable to discriminate or predict perioperative respiratory complications in our population undergoing an adenotonsillectomy.
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Hii J, Templeton TW, Sommerfield D, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia-Part 1 patient and surgical factors. Paediatr Anaesth 2022; 32:209-216. [PMID: 34897906 DOI: 10.1111/pan.14377] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 01/22/2023]
Abstract
Pediatric surgery cases are increasing worldwide. Within pediatric anesthesia, perioperative respiratory adverse events are the most common precipitant leading to serious complications. They can have intraoperative impact on the surgical procedure itself, lead to premature case termination and in addition may have postoperative impact resulting in longer hospitalization stays and costs. Although most perioperative respiratory adverse events can be promptly detected and managed, and will not lead to any sequelae, the risk of life-threatening progression remains. The incidence of respiratory adverse events increases in children with comorbid respiratory and/or nonrespiratory illnesses. Optimized perioperative patient care, risk-stratified care level choice, and practitioners with appropriate training allow for risk mitigation. This review will discuss patient and surgical risk factors with a focus on common patient comorbid illnesses and review scoring systems to quantify risk.
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Affiliation(s)
- Justin Hii
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - T Wesley Templeton
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David Sommerfield
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Aine Sommerfield
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Clyde T Matava
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Termerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Britta S von Ungern-Sternberg
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
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10
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Tong C, Liu P, Zhang K, Liu T, Zheng J. A novel nomogram for predicting respiratory adverse events during transport after interventional cardiac catheterization in children. Front Pediatr 2022; 10:1044791. [PMID: 36340703 PMCID: PMC9631021 DOI: 10.3389/fped.2022.1044791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/30/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The rate and predictors of respiratory adverse events (RAEs) during transport discharged from operating room after interventional cardiac catheterization in children remain unclear. This study aimed to investigate the incidence and predictors, and to construct a nomogram for predicting RAEs during transport in this pediatric surgical treatment. METHODS This prospective cohort study enrolled 290 consecutive pediatric patients who underwent ventricular septal defects (VSD), atrial septal defects (ASD), and patent ductus arteriosus (PDA) between February 2019 and December 2020. Independent predictors were used to develop a nomogram, and a bootstrap resampling approach was used to conduct internal validation. Composite RAEs were defined as the occurrence of at least 1 complication regarding laryngospasm, bronchospasm, apnea, severe cough, airway secretions, airway obstruction, and oxygen desaturation. RESULTS The rate of RAEs during transport was 23.1% (67 out of 290). Multivariate analysis identified age (vs. ≤3 years, adjusted odds ratio (aOR) = 0.507, 95% confidence interval (CI), 0.268-0.958, P = 0.036), preoperative upper respiratory tract infections (URI, aOR = 2.335, 95% CI, 1.223-4.460, P = 0.01), type of surgery (vs. VSD, for ASD, aOR = 2.856, 95% CI, 1.272-6.411, P = 0.011; for PDA, aOR = 5.518, 95% CI, 2.425-12.553, P < 0.001), morphine equivalent (vs. ≤0.153 mg/kg, aOR = 2.904, 95% CI, 1.371-6.150, P = 0.005), atropine usage (aOR = 0.463, 95% CI, 0.244-0.879, P = 0.019), and RAEs during extubation to transport (aOR = 5.004, 95% CI, 2.633-9.511, P < 0.001) as independent predictors of RAEs during transport. These six candidate predictors were used to develop a nomogram, which showed a C-statistic value of 0.809 and good calibration (P = 0.844). Internal validation revealed similarly good discrimination (C-statistic, 0.782; 95% CI, 0.726-0.837) and calibration. Decision curve analysis (DCA) also demonstrated the clinical usefulness of the nomogram. CONCLUSION The high rate of RAEs during transport reminds us of the need for more medical care and attention. The proposed nomogram can reliably identify pediatric patients at high risk of RAEs during transport and guide clinicians to make proper transport plans. Our findings have important and meaningful implications for RAEs risk prediction, clinical intervention and healthcare quality control.
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Affiliation(s)
- Chaoyang Tong
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine and National Children's Medical Center, Shanghai Jiao Tong University, Shanghai, China
| | - Peiwen Liu
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine and National Children's Medical Center, Shanghai Jiao Tong University, Shanghai, China
| | - Kan Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine and National Children's Medical Center, Shanghai Jiao Tong University, Shanghai, China
| | - Ting Liu
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine and National Children's Medical Center, Shanghai Jiao Tong University, Shanghai, China
| | - Jijian Zheng
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine and National Children's Medical Center, Shanghai Jiao Tong University, Shanghai, China
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11
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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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12
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Jankus L, Friesen MA, Barnett SD, Tibbetts J, Faunda M, Swamidoss Douglas C. Selection of Screening Tool for Sleep-Disordered Breathing or Obstructive Sleep Apnea in Pediatric Patients in the Perianesthesia Setting. J Perianesth Nurs 2021; 36:413-419. [PMID: 33752965 DOI: 10.1016/j.jopan.2020.09.006] [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: 06/27/2020] [Revised: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE This study was undertaken to select an appropriate tool to predict risk of obstructive sleep apnea (OSA) among pediatric patients in the preoperative setting. DESIGN/METHODS A retrospective chart review and a survey of nursing staff to compare two tools that were determined to be valid in assessing risk of OSA and postanesthesia complications in pediatric patients aged 6 months to 18 years was conducted. About 300 pediatric patients presenting for elective surgery were screened for OSA using STBUR (Snoring, Trouble Breathing during sleep, struggling to Breathe during Sleep, and waking UnRefreshed) and ST(1)OP-BANG (Snoring, Tonsillar hypertrophy, sleep Obstruction, BMI, Age, Neuromuscular disorders, and Genetic/congenital deformities) concurrently. Six preoperative nurses were then surveyed to compare ease of use and time to complete the screening tools. FINDINGS The STBUR tool was found to predict complications in 37.5% patients versus 22.7% patients with the pediatric ST(1)OP-BANG. Nursing staff found that although both tools were quick and easy to use, the STBUR tool was easier for parents to answer. CONCLUSIONS Use of a screening tool to help predict risk of OSA and postanesthetic complications also helps to dictate anesthesia technique, nursing staffing requirements, and plans of care for postoperative management of pediatric patients.
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Affiliation(s)
- Leilani Jankus
- Inova Fairfax Medical Center, Pediatric Surgery, Inova Health System, Falls Church, VA.
| | - Mary Ann Friesen
- Inova Fairfax Medical Center, Pediatric Surgery, Inova Health System, Falls Church, VA
| | - Scott D Barnett
- Inova Fairfax Medical Center, Pediatric Surgery, Inova Health System, Falls Church, VA
| | - Jacqueline Tibbetts
- Inova Fairfax Medical Center, Pediatric Surgery, Inova Health System, Falls Church, VA
| | - Miriam Faunda
- Inova Fairfax Medical Center, Pediatric Surgery, Inova Health System, Falls Church, VA
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13
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Egbuta C, Mason KP. Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient. J Clin Med 2020; 9:jcm9061942. [PMID: 32580323 PMCID: PMC7355459 DOI: 10.3390/jcm9061942] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022] Open
Abstract
There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.
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14
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Abstract
Since a thorough review in 2011 by Spruyt, into the integral pitfalls of pediatric questionnaires in sleep, sleep researchers worldwide have further evaluated many existing tools. This systematic review aims to comprehensively evaluate and summarize the tools currently in circulation and provide recommendations for potential evolving avenues of pediatric sleep interest. 144 "tool"-studies (70 tools) have been published aiming at investigating sleep in primarily 6-18 years old per parental report. Although 27 new tools were discovered, most of the studies translated or evaluated the psychometric properties of existing tools. Some form of normative values has been established in 18 studies. More than half of the tools queried general sleep problems. Extra efforts in tool development are still needed for tools that assess children outside the 6-to-12-year-old age range, as well as for tools examining sleep-related aspects beyond sleep problems/disorders. Especially assessing the validity of tools has been pursued vis-à-vis fulfillment of psychometric criteria. While the Spruyt et al. review provided a rigorous step-by-step guide into the development and validation of such tools, a pattern of steps continue to be overlooked. As these instruments are potentially valuable in assisting in the development of a clinical diagnosis into pediatric sleep pathologies, it is required that while they are primary subjective measures, they behave as objective measures. More tools for specific populations (e.g., in terms of ages, developmental disabilities, and sleep pathologies) are still needed.
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Affiliation(s)
- Tabitha Sen
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Karen Spruyt
- Lyon Neuroscience Research Center, INSERM U1028-CNRS UMR 5292, University Claude Bernard, School of Medicine, Lyon, France
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15
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Challenges of pediatric obesity in perioperative care. Int Anesthesiol Clin 2020; 58:9-13. [PMID: 32282576 DOI: 10.1097/aia.0000000000000280] [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]
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Ohn M, Eastwood P, von Ungern-Sternberg BS. Preoperative identification of children at high risk of obstructive sleep apnea. Paediatr Anaesth 2020; 30:221-231. [PMID: 31841240 DOI: 10.1111/pan.13788] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/08/2019] [Accepted: 12/10/2019] [Indexed: 12/24/2022]
Abstract
Obstructive sleep apnea is a common childhood disorder which can lead to serious health problems if left untreated. Enlarged adenoid and tonsils are the commonest causes, and adenotonsillectomy is the recommended first line of treatment. Obstructive sleep apnea poses as an anesthetic challenge, and it is a well-known risk factor for perioperative adverse events. The presence and severity of an obstructive sleep apnea diagnosis will influence anesthesia, pain management, and level of monitoring in recovery period. Preoperative obstructive sleep apnea assessment is necessary, and anesthetists are ideally placed to do so. Currently, there is no standardized approach to the best method of preoperative screening for obstructive sleep apnea. Focused history, clinical assessments, and knowledge regarding the strengths and limitations of available obstructive sleep apnea assessment tools will help recognize a child with obstructive sleep apnea in the preoperative setting.
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Affiliation(s)
- Mon Ohn
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA, Australia.,Medical School, The University of Western Australia, Crawley, WA, Australia.,Telethon Kids Institute, Nedlands, WA, Australia
| | - Peter Eastwood
- Centre for Sleep Science, School of Human Sciences, The University of Western Australia, Crawley, WA, Australia.,West Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Britta S von Ungern-Sternberg
- Medical School, The University of Western Australia, Crawley, WA, Australia.,Telethon Kids Institute, Nedlands, WA, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia
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17
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Pediatric obstructive sleep apnea screening questionnaire and post-operative outcomes: A prospective observational study. Int J Pediatr Otorhinolaryngol 2019; 127:109661. [PMID: 31476606 DOI: 10.1016/j.ijporl.2019.109661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/25/2019] [Accepted: 08/25/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Obstructive Sleep Apnea (OSA) and Sleep Disordered Breathing (SDB) in children tend to be a more complex and multifactorial disease than in adults. Although adult screening tools, such as the STOP-BANG questionnaire, their application limited in pediatrics. We used our previously described 6-point questionnaire to identify OSA in children and evaluated its use for predicting post-operative respiratory events. METHODS Children from 3 to 18 years of age presenting for surgery were eligible. Exclusion criteria were emergency surgery or refusal to participate. A 6-question survey regarding symptoms of OSA/SDB was administered preoperatively. Neck circumference was measured. Height and weight were recorded from preoperative data and the body mass index (BMI) percentile obtained. RESULTS 749 patients were enrolled in the study. 707 patients were in the final analysis (359 boys and 348 girls, mean age 12 ± 4 years). The median 6-item questionnaire score was 1 (interquartile range: 0, 2) and 186 (26%) scored ≥ 2 of 6 points. Children with predicted OSA (yes on ≥ 2 questions) were more likely than without predicted OSA to require supplemental oxygen in the PACU (24% vs. 17%; 95% confidence interval [CI] of difference: -0.3%, 13%; p = 0.049). Amongst 681 patients with available data on Post Anesthesia Care Unit (PACU) length of stay (LOS), prolonged LOS (>1 h) was not more likely among children with predicted OSA (42%) compared to those without predicted OSA (39%; 95% CI of difference: -5%, 11%; p = 0.479). Outcomes assessed after PACU discharge noted no differences. Specifically, overnight hospital stay was required in 33% of patients with predicted OSA as compared to 29% of those without (95% CI of difference: -4%, 11%; p = 0.399). On POD 0, supplemental oxygen was used on the inpatient ward for 6% of patients with predicted OSA compared to 4% of patients without predicted OSA (95% CI of difference: -2%, 6%; p = 0.272). CONCLUSION The incidence of OSA/SDB is under-appreciated in children presenting for non-otolaryngological surgical procedures. Although patients judged to have OSA on the 6-item question may need for supplemental oxygen longer in the PACU, no other outcomes differences were noted.
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18
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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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19
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Epidemiology and incidence of severe respiratory critical events in ear, nose and throat surgery in children in Europe: A prospective multicentre observational study. Eur J Anaesthesiol 2019; 36:185-193. [PMID: 30640246 DOI: 10.1097/eja.0000000000000951] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ear, nose and throat (ENT) surgery, the most frequently performed surgical procedure in children, is a strong predictor for peri-operative respiratory complications. However, there is no clear information about peri-operative respiratory severe critical events (SCEs) associated with anaesthesia management of ENT children in Europe. OBJECTIVE To characterise the epidemiology and incidence of respiratory SCEs during and following ENT surgery in Europe and to identify the risk factors for their occurrence. DESIGN A secondary analysis of the Anaesthesia PRactice In Children Observational Trial, a prospective observational multicentre cohort trial. SETTING The study included 261 centres across 33 European countries and took place over a consecutive 2-week recruitment period between April 2014 and January 2015. PATIENTS We extracted data from 5592 ENT surgical procedures that were performed on 5572 children aged 6.0 (3.6) years (mean (SD)) from the surgical database and compared these with data from 15 952 non-ENT surgical children aged 6.7 (4.8) years. MAIN OUTCOME MEASURES The primary outcome was the incidence of respiratory SCEs (laryngospasm, bronchospasm and new onset of postoperative stridor). Secondary outcomes were the differences in epidemiology between ENT children and non-ENT surgical children and the risk factors for the occurrence of respiratory SCEs. RESULTS The incidence (95% confidence interval) of any respiratory SCE (laryngospasm, bronchospasm and postoperative stridor) was 3.93% (3.46 to 4.48) and was significantly higher than that observed in non-ENT surgical children [2.61% (2.37 to 2.87)], with a relative risk of 1.51 (1.28 to 1.77), P less than 0.0001. Younger age (14% decrease in critical events by increasing year, P < 0.0001), history of snoring, recent upper respiratory tract infection and recent wheezing increased the risk of suffering a SCE by over two-fold (P < 0.0001). There was also some evidence for a positive association with age below 4.6 years and lower surgical volume thresholds (<20 cases/2 weeks). CONCLUSION The results of this study provide additional evidence for strong associations between risk factors and respiratory SCEs in children having ENT surgery. These observations may facilitate the implementation of good clinical practice recommendations for ENT patients in Europe. TRIAL REGISTRATION ClinicalTrials.gov, number NCT01878760.
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Abstract
Ambulatory surgery in the pediatric population can be similar to adult ambulatory with a few different challenges. Success is best determined by appropriate preoperative screening. Issues common in pediatrics are the respiratory infection, asthma, congenital heart disease and syndromes, as well as sleep apnea. Risk factors for adverse respiratory events and patient transfer differ from adults as do data for rapid discharge.
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Affiliation(s)
- Steven F Butz
- Medical College of Wisconsin, Milwaukee, WI, USA; Children's Hospital of Wisconsin Surgicenter, 3223 South 103rd Street, Milwaukee, WI 53227, USA.
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21
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Oofuvong M, Ratprasert S, Chanchayanon T. Risk prediction tool for use and predictors of duration of postoperative oxygen therapy in children undergoing non-cardiac surgery: a case-control study. BMC Anesthesiol 2018; 18:137. [PMID: 30384855 PMCID: PMC6214164 DOI: 10.1186/s12871-018-0595-4] [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: 10/17/2017] [Accepted: 09/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to construct a prediction tool for postoperative oxygen therapy and determine predictors of duration of use among children undergoing non-cardiac surgery. METHODS Data from this case-control study was obtained from a database of 9820 children aged < 15 years who underwent general anesthesia between January 2010 and December 2013 at a tertiary care hospital in southern Thailand. The primary outcomes were the use and duration (hours) of postoperative oxygen therapy (cases). Cases were matched with controls on age group and year of surgery in a ratio of 1:4. A negative binomial hurdle model was used to obtain significant predictors of any use and number of hours of oxygen therapy. A risk score was derived from the coefficients of the significant predictors. The risk score, adjusted odds ratio (OR) for any use and count ratio (CR) for duration of postoperative oxygen therapy and 95% confidence interval (CI) were determined. RESULTS A total of 288 cases and 1152 controls were included. The median (inter-quartile range) duration of oxygen therapy delivered was 17 (9-22) hours. An optimal risk score for predictors of oxygen use was 12 (0-32) giving an area under the receiver operating characteristic curve of 0.93. Predictors of high risk need for oxygen therapy (score ≥ 12) were thoracic surgery (OR = 278, 95% CI = 44.6-1733) and having desaturation perioperatively (OR = 459.8, 95% CI = 169.7-1246). Intermediate risk factors (score 8-11) were having bronchospasm (OR = 92.4, 95% CI = 29.7-287.5) and upper airway obstruction/laryngospasm (OR = 61.5, 95% CI = 14.4-262.4) perioperatively. Significant predictors of duration of oxygen therapy were probably difficult airway (CR = 2.2, 95% CI = 1.4-3.5), history of delayed development (CR = 2.3, 95% CI = 1.5-3.6), airway (CR = 3.0, 95% CI = 1.6-5.8), orthopedic (CR = 2.1, 95% CI = 1.1-4.3), thoracic (CR = 4.9, 95% CI = 2.3-10.1) and abdominal surgery (CR = 4.2, 95% CI = 2.1-8.1), compared to eye surgery. CONCLUSIONS Our risk prediction tool for the use of postoperative oxygen therapy provided a high predictive ability. Children who have thoracic surgery, desaturation, bronchospasm, upper airway obstruction or laryngospasm will most likely need postoperative oxygen therapy, regardless of other factors, while those with a probably difficult airway, history of delayed development, or thoracic/abdominal surgery will most likely need longer duration of oxygen therapy.
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Affiliation(s)
- Maliwan Oofuvong
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Road, Songkhla, 90112, Thailand.
| | - Siriwimol Ratprasert
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Road, Songkhla, 90112, Thailand
| | - Thavat Chanchayanon
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, 15 Kanjanavanich Road, Songkhla, 90112, Thailand
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Scalzitti NJ, Sarber KM. Diagnosis and perioperative management in pediatric sleep-disordered breathing. Paediatr Anaesth 2018; 28:940-946. [PMID: 30281185 DOI: 10.1111/pan.13506] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/30/2018] [Accepted: 09/04/2018] [Indexed: 12/17/2022]
Abstract
Sleep-disordered breathing has a prevalence of 12% in the pediatric population. It represents a spectrum of disorders encompassing abnormalities of the upper airway that lead to sleep disruption, including primary snoring, obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation. Sleep-disordered breathing is the most common indication for adenotonsillectomy, one of the most common procedures performed in children. In recent years, the American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, and the American Society of Anesthesiologists have crafted guidelines to help safely manage children with sleep-disordered breathing. Each organization recommends in-laboratory polysomnography for definitive diagnosis of obstructive sleep apnea in certain cases. However, because this test is both costly and inconvenient, there has been significant interest in alternative methods for diagnosing clinically significant sleep-disordered breathing. Accurate diagnosis is critical because sleep-disordered breathing confers certain perioperative risks and increased mortality in some instances. Recent studies have elucidated the danger of anesthesia and opioids in worsening obstructive sleep apnea, and recommendations for alternative analgesia are being created. In addition, determining the most appropriate level and duration of monitoring in the postoperative period is actively being evaluated. This article presents an overview of the recent literature on the perioperative care of pediatric patients with sleep-disordered breathing. It highlights innovative modalities and limitations in diagnosing obstructive sleep apnea, the importance of a tailored anesthetic/analgesic approach to children with obstructive sleep apnea, and the need for postoperative monitoring. It also brings to focus that further studies on the perioperative care of these children are necessary.
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Affiliation(s)
- Nicholas J Scalzitti
- Departments of Otolaryngology and Sleep Medicine, San Antonio Military Medical Center, San Antonio, Texas
| | - Kathleen M Sarber
- Department of Pulmonary Medicine, Sleep Disorders Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Szolnoki J, Polaner DM, Eckle T. Diurnal variations in recovery times after general anaesthesia in children. Br J Anaesth 2018; 121:776-786. [PMID: 30236240 PMCID: PMC6617965 DOI: 10.1016/j.bja.2018.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/14/2018] [Accepted: 06/14/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Circadian rhythms coordinate almost all physiological functions and are implicated in major disease development. Even though circadian rhythms have a major impact on human health, little is known about how they affect general anaesthesia. The purpose of this study was to understand if the time of day affects the length of time a child needs to achieve readiness for discharge after general anaesthesia for brain MRI. METHODS A retrospective analysis over a 3 yr period (2013-5) on the length of stay in the postanaesthesia care unit (PACU) before discharge was performed for children (age <18 yr) undergoing brain magnetic resonance imaging as outpatients. PACU duration was correlated to either morning vs afternoon or to time clusters for discharge times (<9 AM, >9 AM <12 PM, >12 PM <3 PM, >3 PM <6 PM, >6 PM). RESULTS Data from 2340 procedures in children, with median age [inter-quartile range (range)] of 4.7 [2.3-7.25 (0.5-17.8)] yr were available for analysis. The length of stay in the PACU significantly increased over the course of the day with an observed maximum increase of 18 or 19 min (<9 AM vs >6 PM) in children older than 3 or 5 yr, respectively. Subgroup analysis suggested time of day dependent PACU time increase was independent of sex, co-medications, or obstructive sleep apnoea. CONCLUSION The time of day significantly affects PACU recovery times in children of both genders having brain imaging under general anaesthesia. Children younger than 3 yr might not be affected. Further validation of these findings may guide future strategies to reduce discharge times.
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Affiliation(s)
- J Szolnoki
- Department of Anaesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Anaesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | - D M Polaner
- Department of Anaesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Anaesthesiology, Children's Hospital Colorado, Aurora, CO, USA
| | - T Eckle
- Department of Anaesthesiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
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24
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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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25
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Ferrari LR. Preoperative Considerations for Pediatric Patients: What Keeps Parents Up at Night? CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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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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Kako H, Tripi J, Walia H, Tumin D, Splaingard M, Jatana KR, Tobias JD, Raman VT. Utility of screening questionnaire and polysomnography to predict postoperative outcomes in children. Int J Pediatr Otorhinolaryngol 2017; 102:71-75. [PMID: 29106880 DOI: 10.1016/j.ijporl.2017.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The prevalence of pediatric obstructive sleep apnea (OSA) has increased concurrently with the increasing prevalence of obesity. We have previously validated a short questionnaire predicting the occurrence of OSA on polysomnography (PSG). This follow-up study assessed the utility of the questionnaire in predicting postoperative outcomes. METHODS Children undergoing surgery and completing a sleep study were prospectively screened for OSA using a short questionnaire. Procedures within 1 year of PSG were included in the analysis. Questionnaires were scored according to a cutoff previously deemed optimal for predicting OSA (apnea-hypopnea index ≥ 5) on the sleep study. Postoperative outcomes included prolonged (>60 min) length of stay (LOS) in the post-anesthesia care unit (PACU) and oxygen requirement in the PACU. RESULTS The study cohort included 185 patients (100/85 male/female) age 8 ± 4 years, undergoing adenotonsillectomy (n = 109), other ear, nose, and throat (ENT) procedures (n = 18), or non-ENT procedures (n = 58). There were 45 patients with OSA documented by PSG and 122 patients identified as likely to have OSA according to questionnaire responses (89% sensitivity, 41% specificity). PACU LOS was prolonged in 55/181 (30%) cases and supplemental oxygen was used in the PACU in 29/181 (16%) cases. In separate multivariable models, supplemental oxygen use in the PACU was more common if a patient scored ≥2/6 points on the short questionnaire scale (OR = 5.0; 95% CI: 1.3, 19.9; p = 0.023) or if the patient was diagnosed with OSA on PSG (OR = 4.6; 95% CI: 1.6, 13.5; p = 0.005). Neither OSA on PSG nor questionnaire score ≥2/6 were associated with prolonged PACU stay. CONCLUSION Both OSA diagnosis based on the AHI and the questionnaire scale achieved comparable predictive value for the need for oxygen use in the PACU. The utility of the questionnaire in predicting rare adverse events (e.g., unplanned admission or rapid response team activation) remains to be determined. Our preliminary results support using a brief questionnaire scale for preoperative risk stratification among children with suspected OSA who have not had a formal sleep study.
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Affiliation(s)
- Hiromi Kako
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, USA.
| | - Jennifer Tripi
- The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Hina Walia
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, USA
| | - Mark Splaingard
- Department of Pediatrics and Division of Pediatric Pulmonology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, Nationwide Children's Hospital and Wexner Medical Center, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, USA
| | - Vidya T Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, USA; Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, USA
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Kozanhan B, Iyisoy MS. Red cell distribution width as a novel predictor of postoperative respiratory adverse events after adenotonsillectomy. Paediatr Anaesth 2017; 27:609-615. [PMID: 28345782 DOI: 10.1111/pan.13138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Respiratory adverse events are commonly observed after adenotonsillectomy in children with sleep-disordered breathing. Preoperative prediction of these events enhances quality of care and resource management in facilities while encouraging precautions against them. Red cell distribution width, a measure of erythrocyte size variability, has recently been linked to adverse outcomes in a variety of disorders. Red cell distribution width has also been found to be associated with severity of obstructive sleep apnea in adults due to hypoxia-mediated inflammation. AIM The objective of this study was to evaluate whether elevated red cell distribution width is associated with postoperative respiratory adverse events in children with symptoms of sleep-disordered breathing. METHODS A prospective, observational, assessor-blinded study was conducted with consecutive children undergoing elective adenotonsillectomy for treatment of sleep-disordered breathing. Under general anesthesia, adenoidectomy was performed by curettage, and tonsillectomy was carried out by dissection. The primary outcome was the occurrence of an adverse event during emergence or in the postanesthesia care unit (PACU). RESULTS Among 287 patients, with mean ± sd age 7.49 ± 3.21, the frequency of respiratory complications during emergence was 62 (22.30%) and in PACU was 56 (20.14%). Mean ± sd red cell distribution width was 14.36 ± 1.06 in patients with complications and higher than that in those without complications 13.53 ± 0.59. Red cell distribution width had an adjusted odds ratio 7.28 (95% CI: 4.30-13.28) and area under the curve value 0.74 (95% CI: 0.67-0.81) to predict postoperative complications. A cutoff value for red cell distribution width was found to be 14.7. CONCLUSION Our study showed that preoperative elevated red cell distribution width is associated with an increased risk of respiratory adverse events in children undergoing adenotonsillectomy for sleep-disordered breathing.
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Affiliation(s)
- Betul Kozanhan
- Department of Anesthesiology and Reanimation, Education and Research Hospital, Konya, Turkey
| | - Mehmet S Iyisoy
- Department of Medical Education and Informatics, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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Tait AR, O'Brien L, Voepel-Lewis T. Reply to Nielsen, Dominic; Visram, Anil, regarding their comment 'Comment on 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 - potential confounders'. Paediatr Anaesth 2017; 27:326-327. [PMID: 28220667 DOI: 10.1111/pan.13090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alan R Tait
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Louise 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
| | - Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
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Bauer EE, Lee R, Campbell YN. Preoperative Screening for Sleep-Disordered Breathing in Children: A Systematic Literature Review. AORN J 2016; 104:541-553. [DOI: 10.1016/j.aorn.2016.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 02/19/2016] [Accepted: 10/05/2016] [Indexed: 10/20/2022]
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Isaiah A, Szmuk P, Do H, Gonzalez A, Steiner JW. The Challenges of Pediatric Anesthesia for Ambulatory Adenotonsillectomy. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0178-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Raman VT, Splaingard M, Tumin D, Rice J, Jatana KR, Tobias JD. Reply to Tait, Alan; Voepel-Lewis, Terri; Christensen, Robert; O'Brien, Louise, regarding their comment on 'Utility of screening questionnaire, obesity, neck circumference, and sleep polysomnography to predict sleep-disordered breathing in children and adolescents'. Paediatr Anaesth 2016; 26:1028-9. [PMID: 27600759 DOI: 10.1111/pan.12977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Vidya T Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA. .,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, OH, USA.
| | - Mark Splaingard
- Department of Pediatrics and Division of Pediatric Pulmonology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Julie Rice
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, 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 & Pain Medicine, The Ohio State University, Columbus, OH, USA
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Tait AR, Voepel-Lewis T, Christensen R, O'Brien LM. Comment on 'Utility of screening questionnaire, obesity, neck circumference, and sleep polysomnography to predict sleep-disordered breathing in children and adolescents. Paediatr Anaesth 2016; 26:858. [PMID: 27370524 DOI: 10.1111/pan.12952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alan R Tait
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert Christensen
- Department of Anesthesiology, 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
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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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Raman VT, Splaingard M, Tumin D, Rice J, Jatana KR, Tobias JD. Utility of screening questionnaire, obesity, neck circumference, and sleep polysomnography to predict sleep-disordered breathing in children and adolescents. Paediatr Anaesth 2016; 26:655-64. [PMID: 27111886 DOI: 10.1111/pan.12911] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Polysomnography (PSG) remains the gold standard for diagnosing obstructive sleep apnea (OSA) and sleep-disordered breathing in children. Yet, simple screening tools are needed as it is not feasible to perform PSG in all patients with possible OSA. AIM The study adapted questions from the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (SRBD) Questionnaire to develop a predictive scale for OSA identified on PSG. We also tested whether adding anthropometric measurements (body mass index and neck circumference) improved prediction of OSA. METHODS After IRB approval, OSA questionnaires and anthropometric measurements were collected on 948 consecutive patients scheduled for PSG, aged 4 months to 24.5 years (median = 8.5 years). The sample was reduced to 636 patients in the age range (6-18 years old) where normative values for neck circumference are defined. OSA was characterized using the obstructive apnea-hypopnea index (AHI). After identifying questions related to OSA in univariate logistic regression, multivariable models were fitted to select questions for a short scale, and points for exceeding body mass or neck circumference cutoffs were added to assess improvement in predictive value. RESULTS A long scale of 16 questionnaire items was constructed using univariate models, while six items were selected for the short scale by multivariable regression. The short scale was associated with greater odds of moderate/severe OSA (OR = 1.964; 95% CI = 1.620, 2.381; P < 0.001) and attained good predictive value (area under receiver operating characteristics curve [AUC] = 0.74), which was not significantly improved by addition of BMI and neck circumference data (AUC = 0.75). CONCLUSIONS We developed a six-question scale with good predictive utility for OSA. These findings may contribute to developing a preoperative clinical tool to help clinicians identify children with OSA for determining risk stratification and postoperative disposition.
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Affiliation(s)
- Vidya T Raman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Mark Splaingard
- Department of Pediatrics and Division of Pediatric Pulmonology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Julie Rice
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kris R Jatana
- Department of Pediatric Otolaryngology, 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 & Pain Medicine, The Ohio State University, Columbus, OH, USA
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Subramanyam R, Yeramaneni S, Hossain MM, Anneken AM, Varughese AM. Perioperative Respiratory Adverse Events in Pediatric Ambulatory Anesthesia. Anesth Analg 2016; 122:1578-85. [DOI: 10.1213/ane.0000000000001216] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Paine KM, Paliga JT, Tahiri Y, Fischer JP, Wes AM, Wink JD, Gelder CAH, Taylor JA. An Assessment of 30-Day Complications in Primary Cleft Palate Repair: A Review of the 2012 ACS NSQIP Pediatric. Cleft Palate Craniofac J 2016; 53:357-62. [DOI: 10.1597/14-193] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective This study uses the American College of Surgeons Pediatric National Surgical Quality Improvement Program (ACS NSQIP Pediatric), a multicenter database, to identify risk factors for complications after cleft palate repair. Design Patients undergoing Current Procedural Terminology (CPT) codes 42200 and 42205 were extracted from the 2012 ACS NSQIP Pediatric. Patients older than 36 months or those who had undergone an additional surgery that altered the risk were excluded. Outcome variables were combined to create a complication variable. Fisher's exact, Pearson chi-square, and Wilcoxon rank-sum tests were used for analysis. Results Eligibility criteria were met by 751 patients. Of these, 192 (25.6%) had unilateral clefts, 146 (19.4%) bilateral, and 413 (55.0%) were unspecified. The average age at time of surgery for those without and with complications was 421.1 ± 184.8 and 433.6 ± 168.0 days, respectively ( P = .76). Of the 21 (2.8%) patients with complications, respiratory complications were the most common. Risk factors associated with complications included American Society of Anesthesiologists classification of 3 ( P = .003), nutritional support ( P = .013), esophageal/gastric/intestinal disease ( P = .016), oxygen support ( P = .003), structural pulmonary/airway abnormality ( P = .011), and impaired cognitive status ( P = .009). Patients undergoing concurrent laryngoscopy ( P = .048) or other surgeries ( P = .047) were also found to be associated with increased complications. The 30-day fistula rate was 0.5%, and the readmission rate was 1.9%. Conclusion Perioperative complications for primary palatoplasty were 2.8% according to the ACS NSQIP Pediatric. Preoperative patient-related factors as well as concurrent surgeries may affect 30-day complication rates. These results help target those at greater risk for complications and allow for appropriate interventions to mitigate risks.
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Affiliation(s)
- Kaitlyn M. Paine
- Division of Plastic Surgery, the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J. Thomas Paliga
- Division of Plastic Surgery, the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Youssef Tahiri
- Division of Plastic Surgery, the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John P. Fischer
- Division of Plastic Surgery, the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ari M. Wes
- Division of Plastic Surgery, the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jason D. Wink
- Division of Plastic Surgery, the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carol Ann H. Gelder
- Office of Patient Safety and Quality, the Children's Hospital of Philadelphia
| | - Jesse A. Taylor
- Division of Plastic Surgery, the Perelman School of Medicine at the University of Pennsylvania, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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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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Tait AR, Voepel-Lewis T, O'Brien LM. Postsurgical behaviors in children with and without symptoms of sleep-disordered breathing. Perioper Med (Lond) 2014; 3:8. [PMID: 25324968 PMCID: PMC4199245 DOI: 10.1186/2047-0525-3-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 09/23/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although some children undergo formal preoperative testing for obstructive sleep apnea, it is likely that many children present for surgery with undetected sleep-related disorders. Given that these children may be at increased risk during the perioperative period, this study was designed to compare postoperative behaviors between those with and without symptoms of sleep-disordered breathing (SDB). METHODS This study represents a secondary analysis of data from a study examining the effect of SDB on perioperative respiratory adverse events in children. Parents of children aged 2-14 years completed the Sleep-Related Breathing Disorder (SRBD) subscale of the Pediatric Sleep Questionnaire prior to surgery. Children were classified as having SDB if they had a positive score (≥0.33) on the SRBD subscale. Seven to ten days following surgery, the SRBD subscale was re-administered to the parents who also completed the Children's Post Hospitalization Behavior Questionnaire. Children were classified as exhibiting increased problematic behaviors if their postoperative behaviors were considered to be "more/much more" relative to normal. RESULTS Three hundred thirty-seven children were included in this study. Children with SDB were significantly more likely to exhibit problematic behaviors following surgery compared with children without SDB. Logistic regression identified adenotonsillectomy (OR 9.89 [3.2-30.9], P < 0.01) and posthospital daytime sleepiness (OR 2.8 [1.3-5.9], P < 0.01) as risk factors for postoperative problematic behaviors. CONCLUSIONS Children presenting for surgery with symptoms of SDB have an increased risk for problematic behaviors following surgery. These results are potentially important in questioning whether the observed increase in problematic behaviors is biologically grounded in SDB or simply a response to poor sleep habits/hygiene.
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Affiliation(s)
- Alan R Tait
- Department of Anesthesiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Terri Voepel-Lewis
- Department of Anesthesiology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Louise M O'Brien
- Department of Neurology, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA ; Department of Oral/Maxillofacial Surgery, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA ; Michael S. Aldridge Sleep Disorders Center, University of Michigan Health System, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
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