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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 2024; 139:590-597. [PMID: 37307227 DOI: 10.1213/ane.0000000000006593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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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Wilson SH, Hellman KM, James D, Adler AC, Chandrakantan A. Mechanisms, Diagnosis, and Medical Management of Hyperalgesia: an Educational Review. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00485-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Adler AC, Chandrakantan A, Nathanson BH, von Ungern-Sternberg BS. An assessment of opioids on respiratory depression in children with and without obstructive sleep apnea. Paediatr Anaesth 2021; 31:977-984. [PMID: 34053151 DOI: 10.1111/pan.14228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Obstructive sleep apnea is a risk factor for respiratory depression following opioid administration as well as opioid-induced hyperalgesia. Little is known on how obstructive sleep apnea status is associated with central ventilatory depression in pediatric surgical patients given a single dose of fentanyl. METHODS This was a single-center, prospective trial in children undergoing surgery requiring intubation and opioid administration. Sixty patients between the ages of 2-8 years presenting for surgery at Texas Children's Hospital were recruited. Twenty non-obstructive sleep apnea controls and 30 patients with moderate to severe obstructive sleep apnea met inclusion criteria. Following induction of general anesthesia and establishment of steady-state ventilation, participants received 1 mcg/kg intravenous fentanyl. Ventilatory variables (tidal volume, respiratory rate, end-tidal CO2 , and minute ventilation) were assessed each minute for 10 min. The primary outcome was the extent of opioid-induced central ventilatory depression over time by obstructive sleep apnea status when compared with baseline values. Secondary aims assessed the impact of demographics and SpO2 nadir on ventilatory depression. RESULTS We found no significant difference in percent decrease in respiratory rate (38.1% and 37.1%; p = .950), tidal volume (6.4% and 5.4%; p = .992), and minute ventilation (35.0 L/min and 35.0 L/min; p = .890) in control and obstructive sleep apnea patients, respectively. Both groups experienced similar percent increases in end-tidal CO2 (4.0% vs. 2.2%; p = .512) in control and obstructive sleep apnea patients, respectively. CONCLUSIONS In pediatric surgical patients, obstructive sleep apnea status was not associated with significant differences in central respiratory depression following a single dose of fentanyl (1 mcg/kg). These findings can help determine safe opioid doses in future pediatric obstructive sleep apneapatients.
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Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | | | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, WA, Australia.,Telethon Kid's Institute, Perioperative Medicine Team, Perth, WA, Australia
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Bao JL, Xinyuan-Gao, Han YB, Zhang K, Liu L. Efficacy and safety of montelukast for pediatric obstructive sleep apnea syndrome: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e23958. [PMID: 33545976 PMCID: PMC7837961 DOI: 10.1097/md.0000000000023958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pediatric obstructive sleep apnea syndrome (OSAS) is significant public concern. Clinical practice indicates that montelukast has certain therapeutic advantages, while there is a lack of evidence-based medicine support. The aim of this study is to synthesize related data to explore efficacy and safety of montelukast for pediatric OSAS. METHODS Data in Pubmed, EMBASE, CENTRAL, CBM, CNKI, WanFang, VIP databases were comprehensively searched. All the randomized controlled trials (RCTs) in OSAS children were identified, in which the effects of montelukast on a range of outcomes were compared. The search had a deadline of January 1, 2020. Two investigators independently conducted data extraction and assessed the literature quality of the included studies. The Revman5.3 software was used for meta-analysis of the included literature. RESULTS The efficacy and safety of montelukast in the treatment of pediatric OSAS were evaluated in terms of apnea hypopnea index (AHI), the Pittsburgh Sleep Quality Index, the Epworth Sleep Scale (ESS), neck circumference, important index in Polysomnography: sleep efficiency, desaturation index, total sleep time. CONCLUSIONS This study provides reliable evidence-based support for the clinical application of montelukast in the treatment of pediatric OSAS. PROSPERO REGISTRATION NUMBER CRD42020146940.
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Affiliation(s)
- Jun-Li Bao
- Heilongjiang University of Chinese Medicine, No.24, Heping Road, Xiangfang District, Haerbin
| | - Xinyuan-Gao
- Heilongjiang University of Chinese Medicine, No.24, Heping Road, Xiangfang District, Haerbin
| | - Yu-Bo Han
- Fist Affiliated Hospital, Heilongjiang University of Chinese Medicine, Haerbin, Heilongjiang, China
| | - Ke Zhang
- Heilongjiang University of Chinese Medicine, No.24, Heping Road, Xiangfang District, Haerbin
| | - Li Liu
- Fist Affiliated Hospital, Heilongjiang University of Chinese Medicine, Haerbin, Heilongjiang, China
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Adler AC, Daszkowski A, Tan JC, Poliner AD, Wei EZ, Nathanson BH, Chandrakantan A. The Association of Dexmedetomidine on Perioperative Opioid Consumption in Children Undergoing Adenotonsillectomy With and Without Obstructive Sleep Apnea. Anesth Analg 2021; 133:1260-1268. [PMID: 33591119 DOI: 10.1213/ane.0000000000005410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Dexmedetomidine is used to reduce opioid consumption in pediatric anesthesia. However, there is conflicting evidence in pediatric adenotonsillectomy literature regarding the total perioperative opioid-sparing effects of dexmedetomidine. The aim of this study was to examine the association between dexmedetomidine and total perioperative opioid consumption in children undergoing adenotonsillectomy. METHODS This was a retrospective cohort study of the children undergoing adenotonsillectomy surgery at Texas Children's Hospital between November 2017 and October 2018. Intraoperative dexmedetomidine was the exposure of interest. The primary outcome was total perioperative opioid consumption calculated as oral morphine equivalents (OME). Secondary outcomes of interest included opioid consumption and pain scores based on presence and absence of obstructive sleep apnea (OSA) and postanesthesia care unit (PACU) duration. We used multivariable linear regression to estimate the association of dexmedetomidine on the outcomes. RESULTS A total of 941 patients met inclusion criteria, 697 (74.1%) received intraoperative dexmedetomidine. For every 0.1 µg/kg increase in intraoperative dexmedetomidine, the total perioperative OME (mg/kg) decreases by 0.021 mg/kg (95% CI, -0.027 to -0.015; P < .001). Pain scores did not significantly vary by OSA status. PACU duration increased by 1.14 minutes (95% CI, 0.30-1.99; P = .008) for each 0.1 µg/kg of intraoperative dexmedetomidine. CONCLUSIONS Dexmedetomidine is associated with an overall perioperative opioid-sparing effect in children undergoing adenotonsillectomy and a small but statistically significant increase in PACU duration. Additionally, children with OSA did not have reduced perioperative opioid consumption.
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Affiliation(s)
- Adam C Adler
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | | | - Joy C Tan
- Department of Anesthesiology and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Eric Z Wei
- Baylor College of Medicine, Houston, Texas
| | | | - Arvind Chandrakantan
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
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Adler AC, Chandrakantan A, Dang TV, Lee AD, Austin PF. Parental Assessment of Pain Control Following Pediatric Circumcision: Do Opioids Make a Difference? Urology 2021; 154:263-267. [PMID: 33412222 DOI: 10.1016/j.urology.2020.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine whether a postoperative prescription for opioids affects parental assessment of pain control following pediatric circumcision. METHODS This postoperative survey assessed the parental assessment of pain control in 199 patients, ages<18 years undergoing circumcision. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 2018 to January 2020. Postoperative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for postoperative analgesia based on the surgical preference. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric circumcision as poor or inadequate based on the postoperative analgesic regimen. RESULTS Of the 502 surveys sent, the response rate was 40% (199/502) of those who received the survey email, and 64% (199/308) for those who opened the email. Between the opioid and nonopioid groups, there was no difference in, race/ethnicity (Caucasian; 28% vs 37%; P = .43) or insurance status (insured; 51% vs 45%; P = .44). The proportion of parents who rated their child's pain as poor or inadequately controlled following circumcision was relatively rare:5.5% and 1.1% in the nonopioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following circumcision were 61% and 53% in the nonopioids and opioid groups, respectively. CONCLUSION The results of this study indicate that nonopioid analgesic regimens following pediatric circumcision were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric circumcision is feasible and does not result in worse parental satisfaction with the analgesic plan.
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Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children's Hospital; Baylor College of Medicine, Houston, TX.
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children's Hospital; Baylor College of Medicine, Houston, TX
| | | | - Andrew D Lee
- Department of Anesthesiology, Perioperative and Pain Medicine; Texas Children's Hospital
| | - Paul F Austin
- Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital; Baylor College of Medicine, Houston, TX
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Chandrakantan A, Mehta D, Adler AC. Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist. Int J Pediatr Otorhinolaryngol 2020; 139:110420. [PMID: 33035805 DOI: 10.1016/j.ijporl.2020.110420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/10/2023]
Abstract
Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.
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Affiliation(s)
| | - Deepak Mehta
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Adam C Adler
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Musso MF, Lindsey HM, Wilde EA, Hunter JV, Glaze DG, Goodrich-Hunsaker NJ, Wu TC, Black G, Biekman B, Zhang W, Zhu H, Anand GS, Friedman EM. Volumetric brain magnetic resonance imaging analysis in children with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2020; 138:110369. [PMID: 32927352 DOI: 10.1016/j.ijporl.2020.110369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Pediatric Obstructive Sleep Apnea (OSA) is associated with neurocognitive deficits. Cerebral structural alterations in the frontal cortex, cerebellum, and hippocampus have been reported in adult OSA patients. These brain areas are important for executive functioning, motor regulation of breathing, and memory function, respectively. Corresponding evidence comparing cerebral structures in pediatric OSA patients is limited. The objective of this study is to investigate MRI differences in cortical thickness and cortical volume in children with and without OSA. STUDY DESIGN Prospective, single institutional case-control study. METHODS Forty-five children were recruited at a pediatric tertiary care center (27 with OSA; mean age 9.9 ± 1.9 years, and 18 controls; mean age 10.5 ± 1.0 years). The OSA group underwent magnetic resonance imaging (MRI), polysomnography (PSG) and completed the Pediatric Daytime Sleepiness Scale (PDSS) and the Child's Sleep Habits Questionnaire (CSHQ). High-resolution T1-weighted MRI was utilized to examine cortical thickness and gray and white matter volume in children with OSA compared to a healthy group of demographically-comparable children without OSA selected from a pre-existing MRI dataset. RESULTS Children with OSA showed multiple regions of cortical thinning primarily in the left hemisphere. Reduced gray matter (GM) volume was noted in the OSA group in multiple frontal regions of the left hemisphere (superior frontal, rostral medial frontal, and caudal medial frontal regions). Reduced white matter (WM) volume in both the left and right hemisphere was observed in regions of the frontal, parietal, and occipital lobes in children with OSA. CONCLUSION This study noted differences in cortical thickness and GM and WM regional brain volumes in children with OSA. These findings are consistent with other pediatric studies, which also report differences between healthy children and those with OSA. We found that the severity of OSA does not correlate with the extent of MRI alterations.
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Affiliation(s)
- Mary Frances Musso
- Department of Otolaryngology and Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Pediatric Otolaryngology and Head and Neck Surgery, Texas Children's Hospital, Houston, TX, USA.
| | - Hannah M Lindsey
- Department of Neurology, University of Utah, Salt Lake City, UT, USA; Department of Psychology, Brigham Young University, Provo, UT, USA
| | - Elisabeth A Wilde
- Department of Neurology, University of Utah, Salt Lake City, UT, USA; H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA; Department of Radiology, Baylor College of Medicine, Houston, TX, USA; Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Jill V Hunter
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA; Department of Radiology, Baylor College of Medicine, Houston, TX, USA; Department of Pediatric Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Daniel G Glaze
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA; Department of Neurology, Texas Children's Hospital, Houston, TX, USA; Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Naomi J Goodrich-Hunsaker
- Department of Neurology, University of Utah, Salt Lake City, UT, USA; Department of Psychology, Brigham Young University, Provo, UT, USA
| | - Trevor C Wu
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA; Hauenstein Neurosciences, Mercy Health St. Mary's, Grand Rapids, MI, USA; Department of Translational Science and Molecular Medicine, Michigan State University, MI, USA
| | - Garrett Black
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Brian Biekman
- H. Ben Taub Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Wei Zhang
- Department of Pediatric Otolaryngology and Head and Neck Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Huirong Zhu
- Department of Pediatric Otolaryngology and Head and Neck Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Grace Shebha Anand
- Department of Otolaryngology and Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Pediatric Otolaryngology and Head and Neck Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Ellen M Friedman
- Department of Otolaryngology and Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Pediatric Otolaryngology and Head and Neck Surgery, Texas Children's Hospital, Houston, TX, USA
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Chandrakantan A, Patel D, Glaun M, Mehta D, Musso MF, Patel A, Adler AC. Polysomnography in children with obstructive sleep apnoea and neurocognitive disorders. Clin Otolaryngol 2020; 45:885-888. [DOI: 10.1111/coa.13619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/08/2020] [Accepted: 07/21/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Arvind Chandrakantan
- Baylor College of Medicine Houston TX USA
- Texas Children's Hospital Houston TX USA
| | - Deep Patel
- Baylor College of Medicine Houston TX USA
| | - Mica Glaun
- Baylor College of Medicine Houston TX USA
| | - Deepak Mehta
- Baylor College of Medicine Houston TX USA
- Texas Children's Hospital Houston TX USA
| | - Mary F. Musso
- Baylor College of Medicine Houston TX USA
- Texas Children's Hospital Houston TX USA
| | - Amee Patel
- Baylor College of Medicine Houston TX USA
- Texas Children's Hospital Houston TX USA
| | - Adam C. Adler
- Baylor College of Medicine Houston TX USA
- Texas Children's Hospital Houston TX USA
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