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Efune PN, Pinales P, Park J, Poppino KF, Mitchell RB, Szmuk P. Pediatric obstructive sleep apnea: a prospective observational study of respiratory events in the immediate recovery period after adenotonsillectomy. Anaesth Crit Care Pain Med 2024; 43:101385. [PMID: 38705239 DOI: 10.1016/j.accpm.2024.101385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Adenotonsillectomy is often curative for pediatric obstructive sleep apnea, yet children remain at high risk of respiratory complications in the postoperative period. We sought to determine the incidence and risk factors for respiratory depression and airway obstruction, as well as clinically apparent respiratory events in the post-anesthesia care unit (PACU) in high-risk children after adenotonsillectomy. METHODS In this prospective cohort study, we enrolled 60 high-risk children having adenotonsillectomy. Our primary outcome was respiratory depression and airway obstruction in the PACU measured using a noninvasive respiratory volume monitor (RVM) and defined by episodes of predicted minute ventilation less than 40% for at least 2 min. We measured clinically apparent respiratory events using continuous observation by trained study staff. RESULTS The median (range) age of our sample was 4 years (1, 16) and 27 (45%) were female. Black and Hispanic race children comprised 80% (n = 48) of our cohort. Thirty-nine (65%) had at least one episode of PACU respiratory depression or airway obstruction measured using the RVM, while only 21 (35%) had clinically apparent respiratory events. Poisson regression demonstrated the following associations with an increase in episodes of respiratory depression and airway obstruction: BMI Z-score less than -1 (estimate 3.91; [95%CI 1.49-10.23]), BMI Z-score 1-2 (estimate 2.04; [1.20-3.48]), and two or more comorbidities (estimate 1.96; [1.11-3.46]). CONCLUSIONS Respiratory volume monitoring in the immediate postoperative period after pediatric high-risk adenotonsillectomy identifies impaired ventilation more frequently than is clinically apparent.
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Affiliation(s)
- Proshad N Efune
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States; Outcomes Research Consortium, 9500 Euclid Avenue Cleveland, OH 44195, United States.
| | - Pedro Pinales
- University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-8876, United States.
| | - Jenny Park
- Southern Methodist University, Department of Biostatistics, 6425 Boaz Lane, Dallas TX 75205, United States.
| | - Kiley F Poppino
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States
| | - Ron B Mitchell
- University of Texas Southwestern Medical Center, Department of Otolaryngology, Head and Neck Surgery, 2001 Inwood Road, Dallas, TX 75390-9035, United States.
| | - Peter Szmuk
- University of Texas Southwestern Medical Center, Department of Anesthesiology and Pain Management, 5323 Harry Hines Blvd, Dallas, TX 75390-8876, United States; Outcomes Research Consortium, 9500 Euclid Avenue Cleveland, OH 44195, United States.
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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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Deitmer T, Beck CE, Becke-Jakob K, Eich C, Hackenberg S, Hoffmann TK, Koitschev A, Löhler J, Röher K, Sittel C, Welkoborsky HJ, Wienke A, Badelt G. [Statement on the lower age limit for outpatient adenotomies and tonsillotomies]. Laryngorhinootologie 2024; 103:17-24. [PMID: 38086413 DOI: 10.1055/a-2216-8474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
At the beginning of 2023, there have been significant changes to the regulations for outpatient surgery in Germany, which were set out in a trilateral self-administration agreement between the umbrella association of statutory health insurance companies, the German Hospital Association and the Federal Association of Statutory Health Insurance Physicians. Among other things, a catalog stated circumstances under which an operation should not be carried out on an outpatient basis or should only be carried out with doubt. This catalog explains the patient's age: up to the first year of life, inpatient performance of a service can be justified. This formulation in itself means that children from one year of age on should regularly undergo outpatient surgery.In the german scientific societies for otolaryngology, head and neck surgery as well as for anesthesiology and intensive care medicine, doubts arose as to whether this age limit could also be scientifically justified for operations in the throat such as adenotomy or tonsillotomy.A search was carried out in international guidelines and in the international literature and the statements were evaluated. The results of this literature search were discussed with representatives of the Pediatric Otorhinolaryngology Working Group (AG PädHNO) of the German Society for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) and the scientific working group for pediatric anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) in conferences.The consensus revealed that a strict age limit of the first year of life is not appropriate for the outpatient performance of adenotomies and tonsillotomies. First of all, specifying a strict age limit is questionable because, regardless of age, a number of other medical and social factors influence the responsible performance of outpatient operations. Furthermore, the age limit of one year is not considered appropriate in view of literature, guidelines and practical experience in the international area. The assessment of the literature and the consideration of the implementation in the international area make an age limit in the range of 2-3 years seem more appropriate.This review provides the responsible doctors with a variety of insights, aspects and arguments so that they can make their decision to carry out these operations on an outpatient or inpatient basis appropriately and responsibly.
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Affiliation(s)
- T Deitmer
- Arbeitsgemeinschaft pädiatrische HNO-Heilkunde (AG PädHNO) der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC), Bonn
| | - C E Beck
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA) der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover
| | - K Becke-Jakob
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA) der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Berufsverband Deutscher Anästhesistinnen und Anästhesisten. Klinik Hallerwiese-Cnopfsche Kinderklinik, Nürnberg
| | - C Eich
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA) der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Abteilung Anästhesie, Kinderintensiv- und Notfallmedizin, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover
| | - S Hackenberg
- Arbeitsgemeinschaft pädiatrische HNO-Heilkunde (AG PädHNO) der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC), Klinik und Poliklinik für Hals-, Nasen- und Ohrenkrankheiten, plastische und ästhetische Operationen, Universitätsklinikum Würzburg
| | - T K Hoffmann
- Arbeitsgemeinschaft pädiatrische HNO-Heilkunde (AG PädHNO) der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC), Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Ulm
| | - A Koitschev
- Arbeitsgemeinschaft pädiatrische HNO-Heilkunde (AG PädHNO) der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC), Klinik für Hals-Nasen-Ohrenkrankheiten, Plastische Operationen, Klinikum Stuttgart
| | - J Löhler
- Deutscher Berufsverband der HNO-Ärzte, Neumünster
| | - K Röher
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA) der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Eppendorf, Hamburg
| | - C Sittel
- Arbeitsgemeinschaft pädiatrische HNO-Heilkunde (AG PädHNO) der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC), Klinik für Hals-Nasen-Ohrenkrankheiten, Plastische Operationen, Klinikum Stuttgart
| | - H J Welkoborsky
- Arbeitsgemeinschaft pädiatrische HNO-Heilkunde (AG PädHNO) der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC), Klinik für HNO-Heilkunde, Krankenhaus Nordstadt, Kliniken Region Hannover
| | - A Wienke
- Fachanwalt für Medizinrecht, Justiziar der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC), Bonn
| | - G Badelt
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA) der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI), Klinik für Anästhesie und Kinderanästhesie, Krankenhaus Barmherzige Brüder Regensburg, Klinik St. Hedwig, Regenburg
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Paul ME, Wallace JG, Coakley BA. An Assessment of the Relationship Between BMI and Children Undergoing Surgical Procedures: A Retrospective Study. Child Obes 2023; 19:249-257. [PMID: 35776521 PMCID: PMC10398724 DOI: 10.1089/chi.2022.0065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: While multiple studies have documented that obesity increases the risk of operative complications among adults, little data exist on how obesity impacts surgical outcomes among children. We aimed to determine if children with obesity have different postoperative outcomes than their peers. Methods: A retrospective chart review was conducted of 875 patients aged between 2 and 18 years who underwent surgery during 2018. Patients were stratified, based on BMI percentile for age, as having less than healthy weight (<5th percentile), healthy weight (5th-84th percentile), excess weight (85th-94th percentile), or obesity (≥95th percentile). Demographic information and data on medical comorbidities and postoperative complications were collected. All analyses were conducted using chi-square or Kruskal-Wallis testing. Results: Eighty-two patients were excluded due to lack of BMI data and 56 were excluded as they had below healthy weight. Of the remaining 737 patients, 475 (64.4%) had healthy weight, 124 (16.8%) had excess weight, and 138 (18.70%) had obesity. Children with obesity had more tonsillectomy/adenoidectomy (p < 0.01) and vascular access (p = 0.04) procedures compared with peers. Additionally, patients with obesity were more likely to have a pre-existing history of liver disease (p < 0.01) and more frequently developed postoperative wound dehiscence (p < 0.01). No other complications occurred more frequently among children with obesity. Conclusions: Children with obesity required more tonsillectomy/adenoidectomy and vascular access procedures. Wound dehiscence was the only complication that was associated with obesity. This suggests that children with obesity are not inherently more prone to experience surgical complications and therefore elective procedures should likely not be deferred until preoperative weight loss is achieved.
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Affiliation(s)
- Megan E. Paul
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian A. Coakley
- Departments of Pediatrics and Surgery, Mount Sinai Health System, New York, NY, USA
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Considerations in Surgical Management of Pediatric Obstructive Sleep Apnea: Tonsillectomy and Beyond. CHILDREN 2021; 8:children8110944. [PMID: 34828657 PMCID: PMC8623402 DOI: 10.3390/children8110944] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022]
Abstract
Obstructive sleep apnea (OSA) is an increasingly recognized disorder with a reported incidence of 5.7% in children. Tonsillectomy (with or without adenoidectomy) in pediatric OSA in otherwise healthy non-obese children has a success rate of approximately 75%. However, the cure rate reported for all children undergoing tonsillectomy varies from 51% to 83%. This article reviews the history of tonsillectomy, its indications, techniques, various methods, risks, and successes. The article also explores other surgical options in children with residual OSA post-tonsillectomy.
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