Airway Events and Critical Care Requirements in Patients with Robin Sequence after Palatoplasty

Background

Patients with Robin sequence (RS) are often thought to be at high-risk for airway complications after cleft palate repair, and may be routinely admitted to the intensive care unit after surgery. This study compares frequency of postoperative airway events in patients with and without RS undergoing palatoplasty, and assesses potential risk factors for needing intensive care.

Methods

A matched cohort study of patients with and without RS undergoing palatoplasty from February 2014 to February 2022 was conducted. Variables of interest included prior management of micrognathia, comorbidities, polysomnography, age and weight at the time of palatoplasty, operative techniques, intubation difficulty, anesthesia duration, and postoperative airway management. Airway events were defined as airway edema, secretions, stridor, laryngospasm, obstruction, and/or desaturation requiring intervention. Logistic regression was performed to identify factors predictive of airway events.

Results

Thirty-three patients with RS and 33 controls were included. There were no statistically significant differences in airway events between groups (eight RS, four controls, P = 0.30). Anesthetic duration over 318 minutes was associated with increased risk of postoperative airway events [(OR) 1.02 (1.00-1.04) (P = 0.04)] for patients with RS, but not for patients in the control cohort.

Conclusions

Postoperative intensive care unit admission is not universally necessary for patients with RS after palatoplasty if intubation was straightforward and there were no concomitant procedures being performed. Patients with longer anesthesia durations were more likely to have postoperative airway events and may need a higher level of care postoperatively.

Comorbidity and Operative Time are Stronger Predictors than Age for Palatoplasty Adverse Airway Events, A NSQIP-P Study of 6668 Cases

BACKGROUND

Adverse airway events (AAEs) are rare but devastating complications following palatoplasty. The purpose of this study is to evaluate patient risk factors for their effect on these complications. We hypothesize that prolonged operative time and the presence of multiple medical comorbidities are risk factors for AAEs.

DESIGN

Retrospective cohort study.

SETTING

Participant hospitals in the Pediatric American College of Surgeons National Surgical Quality Improvement Program year 2016-2019.

PATIENTS

Cases of palatoplasty in children under 3 years of age.

OUTCOMES

Adverse airway events including postoperative reintubation or any requirement of postoperative mechanical ventilation.

RESULTS

A total of 6668 patients met inclusion criteria. The median operative time was 126 min (IQR 82). AAEs were identified in 107 (1.6%) patients. The incidence of risk factors was found to increase with age and AAEs were more prevalent in younger and older patients. Although patients in the older age groups had significantly higher burden of comorbidities, differences in age were not independently associated with AAEs. Following multivariable logistic regressions, operative times greater than 2 h, ASA class ≥3, >3 medical comorbidities, and black race were found to be significant independent risk factors.

CONCLUSIONS

In this large, retrospective database study in palatoplasty, increased operative time, ASA classification ≥3, multiple comorbidities, and black race were independently associated with AAEs.

Mouth Gags: Advantages and Disadvantages

Mouth gags have been in use since 1220 as a solution to the cumbersome limitations encountered when visibility and access to the oral cavity, pharynx, and larynx are needed. The instruments being used today range from the simple but effective design of the bite block to the sophisticated and intricate design of the Feyh-Kastenbauer. This article highlights the most frequently used well-designed mouth gags and the applications for which they provide the most benefit. Disadvantages and risks of their use are explored, especially those that clinicians should be aware of for patient and operator safety.