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Feldman RM, O'Reilly-Shah V, Dahl JP, Siu J, Newby M, Sutherland TN, Parikh SR, Jiang T, Franz A. Impact of Ketorolac on Reoperation for Hemorrhage After Pediatric Tonsillectomy: A Single-Center Retrospective Propensity-Matched Study. Otolaryngol Head Neck Surg 2024; 170:928-936. [PMID: 37925621 DOI: 10.1002/ohn.577] [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: 02/16/2023] [Revised: 09/20/2023] [Accepted: 10/07/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE To determine if perioperative ketorolac is associated with an increased rate of reoperation for hemorrhage after pediatric tonsillectomy at 30 days and 48 hours. STUDY DESIGN Single-center retrospective propensity-matched study. SETTING Quaternary pediatric hospital and ambulatory surgery center. METHODS Patients less than 18 years old undergoing tonsillectomy or adenotonsillectomy between January 1, 2015 and October 1, 2020 were included. Hemorrhage rates between exposed (K+) and unexposed (K-) patients were calculated for the total cohort and a 1:1 propensity-matched cohort. Additional analyses included: multivariable logistic regression, subgroup analysis of ASA 1 and 2 patients, subgroup analysis comparing children with teenagers. RESULTS There were 5873 patients (42.1% K+) in the full cohort and 4694 patients in the propensity-matched cohort. Reoperation for hemorrhage within 30 days occurred in 1.9% of K+ patients and 1.6% of K- patients (P = 0.455) in the full cohort and 1.9% of K+ patients and 1.7% of K- patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.72-1.69, P = 0.662) in the propensity-matched cohort. Reoperation within 48 hours occurred in 0.65% of K+ patients and 0.53% of K- patients (P = 0.679) in the full cohort and 0.68% of K+ patients and 0.51% of K- patients (OR 1.33, 95% CI 0.63-2.81, P = 0.451) in the propensity-matched cohort. There was no association between perioperative ketorolac administration and reoperation for hemorrhage in any of the other analyses. CONCLUSION Ketorolac at end of surgery should be considered as part of the nonopioid analgesic regimen for pediatric tonsillectomy.
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Affiliation(s)
- Rachel M Feldman
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Vikas O'Reilly-Shah
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Jennifer Siu
- Department of Otolaryngology Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Maxwell Newby
- Department of Otolaryngology Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Tori N Sutherland
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay R Parikh
- Department of Otolaryngology Head & Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Teresa Jiang
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Amber Franz
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
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Kanavitoon S, Ngamprasertwong P, Gurbani N, Nakamura A, Hossain MM, Heubi CH, Simakajornboon N. Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty. J Clin Sleep Med 2024; 20:9-16. [PMID: 37584453 PMCID: PMC10758547 DOI: 10.5664/jcsm.10770] [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: 01/23/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 08/17/2023]
Abstract
STUDY OBJECTIVES Postoperative respiratory complications (PORCs) can occur following supraglottoplasty (SGP) for obstructive sleep apnea. However, there are very limited data on risk factors associated with these complications. This study aims to evaluate the occurrence of PORC in children undergoing SGP and to assess clinical factors and polysomnographic parameters predicting these complications. METHODS A retrospective study was performed in children with laryngomalacia who underwent SGP with preoperative polysomnography. RESULTS 400 children who underwent SGP met the criteria for entry into the analysis with a total of 416 surgeries with corresponding preoperative polysomnography. The median age (interquartile range) at the time of polysomnography was 0.4 (0.2, 1.5) years. A total of 96 (23.1%) PORCs were noted. Compared with those without complications, children with PORCs had a higher proportion of congenital heart disease (P < .05), higher median obstructive apnea-hypopnea index (obstructive AHI; median 16.0 vs 11.4 events/h; P < .01), and lower median oxygen saturation (SpO2) (P < .001). The unadjusted odd ratio indicated an increased risk of PORCs in children with congenital heart disease (odds ratio 1.66; P < .05) and those with an obstructive AHI > 10 events/h (odds ratio 2.06; P < .01). Multiple regression analysis demonstrated that an obstructive AHI > 10 events/h was the only independent risk factor for PORCs (P < .05). CONCLUSIONS In our cohort of children with laryngomalacia undergoing SGP, those with underlying congenital heart disease, higher obstructive AHI, and lower SpO2 were more likely to develop PORCs. Only children with an obstructive AHI > 10 events/h were at significantly increased risk for PORCs following SGP. Preoperative polysomnography is useful in preoperative planning in children undergoing SGP. CITATION Kanavitoon S, Ngamprasertwong P, Gurbani N, et al. Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty. J Clin Sleep Med. 2024;20(1):9-16.
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Affiliation(s)
- Sawita Kanavitoon
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Anesthesiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | - Neepa Gurbani
- Division of Pulmonary Medicine and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Aisaku Nakamura
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Md Monir Hossain
- Division of Pulmonary Medicine and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Christine H. Heubi
- Division of Pulmonary Medicine and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Pediatric Otolaryngology—Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Narong Simakajornboon
- Division of Pulmonary Medicine and Sleep Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Omer KA, Mlauzi R, Basera W, McGuire J, Meyer H, Lawrenson J, Peer S, Singh Y, Zampoli M. Low incidence of pulmonary hypertension in children with suspected obstructive sleep apnea: A prospective observational study. Int J Pediatr Otorhinolaryngol 2023; 171:111648. [PMID: 37419069 DOI: 10.1016/j.ijporl.2023.111648] [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: 05/11/2023] [Revised: 06/21/2023] [Accepted: 07/03/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVES Pulmonary hypertension (PH) secondary to obstructive sleep apnea (OSA) is an uncommon but serious perioperative risk factor in children undergoing surgery for adenotonsillar hypertrophy. Routine pre-operative echocardiography is commonly requested if severe OSA is suspected. We investigated the incidence of PH in children with suspected OSA and explored the association between PH and OSA severity. METHODS A prospective study of children aged 1-13 years with suspected OSA admitted for overnight oximetry (OO) and echocardiography at a pediatric referral hospital in Cape Town, South Africa from 2018 to 2019. OSA severity was defined by McGill Oximetry Score (MOS): MOS 1-2 (mild-moderate) and MOS 3-4 (severe). PH was defined as mean pulmonary arterial pressure (mPAP) ≥20 mmHg estimated on echocardiographic criteria. Children with congenital heart disease, underlying cardio-respiratory or genetic disorders, and severe obesity were excluded. RESULTS One hundred and seventy children median age 3.8 years (IQR 2.7-6.4) were enrolled and 103 (60%) were female. Twenty-two (14%) had a BMIz >1.0 and 99 (59%) had tonsillar enlargement grade 3/4. One hundred and twenty-two (71%) and 48 (28%) children had mild-moderate and severe OSA, respectively. Echocardiographic assessment for PH was successful in 160 (94%) children of which eight (5%) had PH with mPAP 20.8 mmHg (SD 0.9): six with mild-moderate OSA and two with severe OSA. No significant difference in mPAP and other echocardiographic indices was observed in children with mild-moderate (16.1 mmHg; SD 2.4) and severe OSA (15.7 mmHg; SD 2.1). Similarly, no clinical and OSA severity differences were observed in children with and without PH. CONCLUSION PH is uncommon in children with uncomplicated OSA and there is no association of PH with severity of OSA measured by OO. Routine echocardiographic screening for PH in children with clinical symptoms of OSA without co-morbidity is unwarranted.
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Affiliation(s)
- Khadar A Omer
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - Raphael Mlauzi
- Division of Otorhinolaryngology, Department of Surgery, University of Cape Town, South Africa
| | - Wisdom Basera
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town. Burden of Disease Research Unit, South African Medical Research Council, South Africa
| | - Jessica McGuire
- Division of Otorhinolaryngology, Department of Surgery, University of Cape Town, South Africa
| | - Heidi Meyer
- Division of Paediatric Anaesthesia, Department of Anaesthesia and Perioperative Medicine, University of Cape Town, South Africa
| | - John Lawrenson
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, University of Cape Town. Department of Paediatrics and Child Health, Stellenbosch University, South Africa
| | - Shazia Peer
- Division of Otorhinolaryngology, Department of Surgery, University of Cape Town, South Africa
| | - Yanita Singh
- Paediatric Cardiology Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Marco Zampoli
- Department of Paediatrics and Child Health, University of Cape Town, South Africa.
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Kelmanson IA. Increased P-wave dispersion in patients with obstructive sleep apnea syndrome: a meta-analysis. Sleep Breath 2023; 27:291-301. [PMID: 35501617 DOI: 10.1007/s11325-022-02630-1] [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: 01/04/2022] [Revised: 04/22/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Prolonged atrial conduction and inhomogeneous sinus impulse propagation may play a role in the initiation and maintenance of atrial tachyarrhythmias. Such a process could be reflected in inter-lead P-wave duration differences known as "P-wave dispersion" (PWD). Abnormal PWD may be related to obstructive sleep apnea syndrome (OSAS). A meta-analysis of the available publications was conducted. METHODS A MEDLINE, Web of Science, and Google Scholar search from 2000 to 2021 was performed. The keywords used for search were apnea AND "P wave dispersion." Case-control studies and surveys were selected as long as they included healthy subjects and subjects with diagnosed OSAS who did not have any other major health problems. PWD values and correlations between apnea-hypopnea indices (AHI) and PWD were used as outcome measures. RESULTS Ten studies met the inclusion creteria, encompassing 773 patients with OSAS and 347 healthy controls. The mean ages of the patients with OSAS ranged from 6.9 to 58.8 years. The estimated average Hedges's g standardized mean difference in PWD values was equal to 1.883 (95% CI: 1.140 to 2.626, p < 0.001). The estimated average Fisher r-to-z transformed correlation coefficient between AHI and PWD was equal to 0.530 (95% CI: 0.075 to 0.985, p = 0.0225). Meta-regression analysis failed to find statistically significant correlations between the effect sizes and the mean age, male proportion, and the body mass index in the OSAS groups. CONCLUSION OSAS is associated with increased PWD, which may predispose to atrial tachyarrythmias.
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Affiliation(s)
- Igor A Kelmanson
- Department of Children's Diseases, Institute for Medical Education of the V.A. Almazov National Medical Research Centre, 2 Akkuratova Str., St Petersburg, 197341, Russia.
- Department of Clinical Psychology, St. Petersburg State Institute for Psychology and Social Work, St Petersburg, Russia.
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Kirkham EM, Puglia MP, Haydar B, Jewell ES, Leis AM, Peddireddy N, Chervin RD. Preoperative Predictors of Severe Respiratory Events After Tonsillectomy: Consideration for Pediatric Intensive Care Admission. Otolaryngol Head Neck Surg 2023; 168:1535-1544. [PMID: 36939624 DOI: 10.1002/ohn.238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/19/2022] [Accepted: 12/03/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Few data are available to guide postadenotonsillectomy (AT) pediatric intensive care (PICU) admission. The aim of this study of children with a preoperative polysomnogram (PSG) was to assess whether preoperative information may predict severe respiratory events (SRE) after AT. STUDY DESIGN Retrospective cohort study. SETTING Single tertiary center. METHODS Children aged 6 months to 17 years who underwent AT with preoperative polysomnography (2012-2018) were identified by billing codes. Data were extracted from medical records. SRE were defined as any 1 or more of desaturations <80% requiring intervention; newly initiated positive airway pressure; postoperative intubation; pneumonia/pneumonitis; respiratory code, cardiac arrest, or death. We hypothesized that SRE would be associated with age <24 months, major medical comorbidity, obesity (>95th percentile), apnea-hypopnea index (AHI) ≥ 30, and O2 nadir <70% on PSG. Analysis was performed with multivariable logistic regression. RESULTS Of 1774 subjects, 28 (1.7%) experienced SRE. Compared to those without, children with SRE were on average younger (3 vs 5 years, p < .01) with a greater probability of medical comorbidities (59% vs 18%, p < .001). After adjustment for sex, black race, obesity, and age <24 months, children with major medical comorbidity were more likely than other children to have SRE (odds ratio [OR]: 14.2; 95% confidence interval [CI]: [5.7, 35.2]), as were children with AHI ≥ 30 (OR: 7.7 [3.0, 19.9]), or O2 nadir <70% (OR 6.1 [2.1, 17.9]). Age, obesity, sex, and black race did not independently predict SRE. CONCLUSION PICU admission may be most prudent for children with complex medical co-morbidities, high AHI (>30), and/or low O2 nadir (<70%).
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Affiliation(s)
- Erin M Kirkham
- Department of Otolaryngology-Head & Neck Surgery, The University of Michigan, Ann Arbor, Michigan, USA
| | - Michael P Puglia
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Bishr Haydar
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth S Jewell
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Aleda M Leis
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Nithin Peddireddy
- Department of Otolaryngology-Head & Neck Surgery, The University of Michigan, Ann Arbor, Michigan, USA
| | - Ronald D Chervin
- Sleep Disorders Center and Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
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Rollins JT, Wajsberg B, Bitners AC, Burton WB, Hametz PA, Chambers TA, Yang CJ. Admission practices following pediatric tonsillectomy: A survey of ASPO members. Int J Pediatr Otorhinolaryngol 2022; 162:111286. [PMID: 36206700 PMCID: PMC11232560 DOI: 10.1016/j.ijporl.2022.111286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/08/2022] [Accepted: 08/12/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Although evidence-based Clinical Practice Guidelines (CPGs) have specified postoperative admission criteria for pediatric tonsillectomy, there is substantial variation in guideline implementation and adherence among otolaryngologists in practice. We aimed to assess pediatric otolaryngologists' post-tonsillectomy admission practices and to examine patient and surgeon factors associated with differences in admission practices. METHODS An electronic cross-sectional survey was distributed to members of the American Society of Pediatric Otolaryngology (ASPO) to determine current practices regarding admission practices following pediatric tonsillectomy. Chi-square and Fisher's exact tests were performed to compare differences in adherence to tonsillectomy CPGs by respondent characteristics. RESULTS The survey was sent to 644 pediatric otolaryngologists with a response rate of 19.1%. 37% of respondents reported "always" and 60% "often" using the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) CPG to guide decision for admission. Years in practice was the factor most strongly associated with admission practices, with 10 or fewer years in practice significantly correlated with stricter adherence to the AAO-HNS CPG of overnight observation when Apnea-Hypopnea Index (AHI) ≥10, age <3 years, or O2 nadir <80%) (OR 4.2, p <0.001), as well as specific individual criteria such as an AHI ≥10 (OR 4.1, p = 0.03). Respondents in an academic practice setting were more likely to admit children <3 years of age than those in private practice (OR 5.0, p = 0.01). CONCLUSION Admission practices varied among pediatric otolaryngologist survey respondents, and strict AAO-HNS CPG adherence was associated with fewer years in practice and academic practice setting. These results suggest that further study investigating factors influencing guideline adherence and post-tonsillectomy admission practices is warranted.
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Affiliation(s)
| | | | - Anna C Bitners
- Johns Hopkins Hospital, Department of Pediatrics, Baltimore, MD, USA
| | | | - Patricia A Hametz
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Pediatrics, Bronx, NY, USA
| | - Terry-Ann Chambers
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Anesthesiology, Bronx, NY, USA
| | - Christina J Yang
- Albert Einstein College of Medicine, Bronx, NY, USA; Montefiore Medical Center, Department of Pediatrics, Bronx, NY, USA; Montefiore Medical Center, Department of Otorhinolaryngology-Head and Neck Surgery, Bronx, NY, USA.
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Predictors of overnight postoperative respiratory complications in obese children undergoing adenotonsillectomy for obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2022; 162:111334. [PMID: 36209625 DOI: 10.1016/j.ijporl.2022.111334] [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: 05/11/2022] [Revised: 08/24/2022] [Accepted: 10/01/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Current clinical guidelines from the American Academy of Otolaryngology Head & Neck Surgery (AAO-HNS) recommend a preoperative polysomnogram (PSG) for obese patients prior to adenotonsillectomy (T&A). An overnight admission is recommended for children with severe (AHI >10) obstructive sleep apnea (OSA), citing a higher incidence of post-operative respiratory complications (PRCs) and need for respiratory support. Routine admission of obese children based on AHI >10 alone after T&A may place undue strain on hospital resources and increase healthcare costs, especially considering that many of these children have uncomplicated postoperative courses. In this study, we sought to identify variables from the pre-operative PSG and post-anesthesia care unit (PACU) that could more accurately predict overnight PRCs and indicate the need for a post-surgical admission after T&A. METHODS A single-center retrospective chart review was performed on a cohort of 155 obese children who underwent adenotonsillectomy for OSA. Inclusion criteria included patients 17 years of age and younger who had BMI 95th percentile or greater, underwent preoperative polysomnography, and were admitted overnight after T&A. Overnight respiratory complications were defined as an O2 desaturation under 92%, the need for overnight airway support, a respiratory support regression, respiratory depression, and bronchospasm/laryngospasm. Multivariable binary logistic regression analysis, point-biserial correlation, and Chi-square tests were performed to assess relationship of BMI z-score, polysomnography parameters, and PACU events with overnight respiratory complications. RESULTS Lower O2 saturation nadirs on polysomnography were an independent predictor of respiratory complications overnight (OR = 0.953, 95% CI = 0.91-0.99, P = 0.021), as was sleep time with O2 saturation less than 90% (OR = 1.04, 95% CI = 1.00-1.07, P = 0.048). A prediction model with preoperative and postoperative variables significant on simple logistic regression yielded a ROC curve with AUC 0.89 (95% CI 0.82, 0.96). At a cutoff point of O2 saturation nadir less than 80%, overnight PRCs were predicted with 70.8% sensitivity and 75.2% specificity. At a cutoff point of greater than 0.5% of sleep time spent with O2 < 90% on PSG, overnight PRCs were predicted with 82.6% sensitivity and 62% specificity. Obstructive apneas (OAI) was not predictive of PRCs. BMI percentile was not significantly correlated with overnight respiratory complications, but BMI z-score was significantly correlated with overnight respiratory depression and an overnight airway event. CONCLUSIONS O2 saturation nadir on PSG and time spent with oxygen saturation <90% (TST90) on PSG were found to be independent predictors of overnight postoperative respiratory complications after adenotonsillectomy in obese children. In addition to reaffirming existing guidelines for postoperative admission of patients with O2 saturation nadir on PSG <80%, these findings also suggest considering postoperative admission for obese patients who experience >0.5% sleep time with O2 sat <90% during PSG due to increased risk of overnight postoperative respiratory complications.
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Than K, Mun-Price C, Klein MJ, Ross PA, Gomez G, Nagoshi M. PICU admission and complications following adenotonsillectomies in pediatric patients: A retrospective cohort study. Int J Pediatr Otorhinolaryngol 2022; 158:111166. [PMID: 35567809 DOI: 10.1016/j.ijporl.2022.111166] [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: 01/06/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Children with obstructive sleep apnea (OSA) have higher risks of post-operative respiratory complication after adenotonsillectomy. However, there is no clinical standard criteria for pediatric intensive care unit (PICU) admission following adenotonsillectomy. The purpose of this study was to identify perioperative risk factors associated with the need for PICU level care after adenotonsillectomy. METHODS We performed a retrospective chart review of children with severe OSA (apnea hypopnea index on polysomnography; AHI ≥10) and/or post-operative PICU admission at a tertiary academic center from May 2010 to September 2018. We collected demographics, pre-existing comorbidities, perioperative medications, and post-operative complications. We defined a primary outcome as escalation of airway management while in the PICU or PICU stay >48 h. Airway escalation included the need for an invasive airway, new CPAP application, increased CPAP setting, or increased supplemental oxygen. RESULTS Analysis included 278 children with severe OSA and/or PICU admission. Median age was 6.6 years old; 181 (65%) were admitted to the PICU, and 60 (21.5%) had the composite outcome of escalation of airway management or prolonged stay. In patients with an escalation of airway management, 28 needed intubation or mechanical ventilation. Multivariable logistic regression showed intraoperative respiratory complications, polysomnography (PSG) peak end-tidal CO2 (EtCO2) reading >60 mmHg, and the presence of neuromuscular disease as significant associated factors for escalation of airway management or prolonged PICU stay (P values < 0.01; odd ratios 3.4, 5.3, and 5.4, respectively). CONCLUSION For children following adenotonsillectomy, PSG EtCO2 ≥ 60%, preexisting neuromuscular disease, and intraoperative complications (hypoxia, difficult airway, etc.) were independently associated with escalation of airway management or prolonged stay. AHI was not an independent predictor for PICU complication. We concluded factors should be considered for PICU admission in addition to AHI.
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Affiliation(s)
- Kathleen Than
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Connie Mun-Price
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Patrick A Ross
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Gomez
- Department of Otolaryngology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Makoto Nagoshi
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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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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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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11
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Templeton TW, Sommerfield D, Hii J, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia-Part 2: Anesthesia-related risk and treatment options. Paediatr Anaesth 2022; 32:217-227. [PMID: 34897894 DOI: 10.1111/pan.14376] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/17/2022]
Abstract
Perioperative respiratory adverse events are the most common cause of critical events in children undergoing anesthesia and surgery. While many risk factors remain unmodifiable, there are numerous anesthetic management decisions which can impact the incidence and impact of these events, especially in at-risk children. Ongoing research continues to improve our understanding of both the influence of risk factors and the effect of specific interventions. This review discusses anesthesia risk factors and outlines strategies to reduce the rate and impact of perioperative respiratory adverse events with a chronologic based inquiry into anesthetic management decisions through the perioperative period from premedication to postoperative disposition.
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Affiliation(s)
- Thomas 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, School of Medicine, University of Western Australia, Crawley, Western Australia, Australia.,Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Justin Hii
- Perioperative Medicine Team, Telethon Kids Institute, Nedlands, Western Australia, Australia.,Department of Anaesthesia, Joondalup Health Campus, Joondalup, 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, School of Medicine, 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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12
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Faramarzi M, Roosta S, Eghbal MH, Nouri Rahmatabadi B, Faramarzi A, Mohammadi‐Samani S, Shishegar M, Sahmeddini MA. Comparison of celecoxib and acetaminophen for pain relief in pediatric day case tonsillectomy: A randomized double-blind study. Laryngoscope Investig Otolaryngol 2021; 6:1307-1315. [PMID: 34938867 PMCID: PMC8665471 DOI: 10.1002/lio2.685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/26/2021] [Accepted: 10/14/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Post-tonsillectomy pain is a common morbidity in children. The aim of this study was to compare the efficacy of celecoxib with acetaminophen on pain relief in pediatric day-case tonsillectomy. METHODS We compared the analgesic effect of celecoxib (99 patients) with acetaminophen (100 patients) for the management of post-tonsillectomy pain. Post-tonsillectomy pain score was evaluated three times a day for 7 days. In addition, the incidence of post-tonsillectomy bleeding and the rate of patients who returned to regular diet were evaluated. RESULTS In the first day, we observed lower mean pain score in the celecoxib group, than the acetaminophen group (P = 0.013). The overall pain score in other days was not significantly different between the two groups. In the celecoxib group, more patients resumed regular amount of oral intake within the first 3 days. Also, the rate of post-tonsillectomy bleeding in the two groups was not statistically different. CONCLUSION We recommend celecoxib as a more suitable choice than acetaminophen for post-tonsillectomy pain management in the first day and resuming regular diet within 3 days.Level of Evidence: 1b.
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Affiliation(s)
- Mohammad Faramarzi
- Department of Otorhinolaryngology – Head & Neck surgeryShiraz University of Medical SciencesShirazIran
- Otolaryngology Research CenterShiraz University of Medical SciencesShirazIran
| | - Sareh Roosta
- Otolaryngology Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Mohammad Hossein Eghbal
- Shiraz Anesthesiology and Critical Care Research CenterShiraz University of Medical SciencesShirazIran
| | - Bahar Nouri Rahmatabadi
- Shiraz Anesthesiology and Critical Care Research CenterShiraz University of Medical SciencesShirazIran
| | - Ali Faramarzi
- Otolaryngology Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | | | - Mahmood Shishegar
- Department of Otorhinolaryngology – Head & Neck surgeryShiraz University of Medical SciencesShirazIran
- Otolaryngology Research CenterShiraz University of Medical SciencesShirazIran
| | - Mohammad Ali Sahmeddini
- Shiraz Anesthesiology and Critical Care Research CenterShiraz University of Medical SciencesShirazIran
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13
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Davidovich E, Hevroni A, Gadassi LT, Spierer-Weil A, Yitschaky O, Polak D. Dental, oral pH, orthodontic and salivary values in children with obstructive sleep apnea. Clin Oral Investig 2021; 26:2503-2511. [PMID: 34677695 DOI: 10.1007/s00784-021-04218-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Mouth breathing is a key feature of obstructive sleep apnea (OSA). The current study evaluated dental, salivary and orthodontic characteristics of children with OSA, and compared them to those of children without OSA. MATERIALS AND METHODS Twenty-two children (mean age 5.3 years, 13 males) with OSA and 21 children without OSA who served as a control group (mean age 6.8 years, 11 males) underwent dental examinations. The OSA group was classified according to the apnea-hypopnea Index. Clinical examination included plaque index, gingival index, caries status, pH at 7 oral sites, salivary carries bacterial counts and inflammatory cytokine levels. Orthodontics measurements were calculated as the percentage of children with values in the normal range, in each group. RESULTS The mean values of the decayed, missing and filled teeth (DMFT)/dmft index, the gingival index and the plaque index were higher in the OSA than the control group. Salivary Mutans streptococci and lactobacilli counts were significantly higher in the OSA than the control group; as were pH values in the hard and soft palate, and in the posterior and middle tongue. Significantly lower values were observed in the OSA than the control group for most of the orthodontic variables examined. Similarly, stratification of AHI according to severity shows the lowest values among those with mild OSA, and the highest among those with severe AHI. CONCLUSIONS Compared to a control group, mouth breathing children with obstructive sleep apnea had differences in oral microbiota, greater acidity and poorer dental status. CLINICAL RELEVANCE Clinicians should be aware of the various oral disturbances that may accompany OSA, and implement preventive measures.
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Affiliation(s)
- E Davidovich
- Department of Pediatric Dentistry, Faculty of Dental Medicine, Hebrew University-Hadassah, Jerusalem, Israel.
| | - A Hevroni
- Department of Pulmonology, Faculty of Dental Medicine, Hebrew University-Hadassah, Jerusalem, Israel
| | - L Tzur Gadassi
- Department of Orthodontics, Faculty of Dental Medicine, Hebrew University-Hadassah, Jerusalem, Israel
| | - A Spierer-Weil
- Department of Pediatric Dentistry, Faculty of Dental Medicine, Hebrew University-Hadassah, Jerusalem, Israel
| | - O Yitschaky
- Department of Orthodontics, Faculty of Dental Medicine, Hebrew University-Hadassah, Jerusalem, Israel
| | - D Polak
- Department of Periodontology, Faculty of Dental Medicine, Hebrew University-Hadassah, Jerusalem, Israel
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14
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Badelt G, Goeters C, Becke-Jakob K, Deitmer T, Eich C, Höhne C, Stuck BA, Wiater A. S1-Leitlinie: Obstruktive Schlafapnoe im Rahmen von Tonsillenchirurgie mit oder ohne Adenotomie bei Kindern – perioperatives Management. SOMNOLOGIE 2021. [DOI: 10.1007/s11818-021-00303-x] [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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15
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Badelt G, Goeters C, Becke-Jakob K, Deitmer T, Eich C, Höhne C, Stuck BA, Wiater A. [German S1 guideline: obstructive sleep apnea in the context of tonsil surgery with or without adenoidectomy in children-perioperative management]. HNO 2020; 69:3-13. [PMID: 33354732 DOI: 10.1007/s00106-020-00970-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
Otolaryngologic surgery is one of the most frequent operative interventions performed in children. Tonsil surgery with or without adenoidectomy due to hyperplasia of the tonsils and adenoids with obstruction of the upper airways with or without tympanic ventilation disorder is the most common of these procedures. Children with a history of sleep apnoea (OSA) suffer from a significantly increased risk of perioperative respiratory complications. Cases of death and severe permanent neurologic damage have been reported due to apnoea and increased opioid sensitivity. The current guideline represents a pragmatic risk-adjusted approach. Patients with confirmed or suspected OSA should be treated perioperatively according to their individual risks and requirements, in order to avoid severe permanent damage.
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Affiliation(s)
- G Badelt
- Klinik für Anästhesie und Kinderanästhesie, Krankenhaus Barmherzige Brüder Regensburg, Klinik St. Hedwig, Steinmetzstraße 1-3, 93049, Regensburg, Deutschland. .,Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland.
| | - C Goeters
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - K Becke-Jakob
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - T Deitmer
- Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V. (DGHNO KHC), Friedrich-Wilhelm-Str. 2, 53113, Bonn, Deutschland
| | - C Eich
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - C Höhne
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - B A Stuck
- Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V. (DGHNO KHC), Friedrich-Wilhelm-Str. 2, 53113, Bonn, Deutschland
| | - A Wiater
- Kinder- und Jugendmedizin/Schlafmedizin, Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM)
- Arbeitsgruppe Pädiatrie im Konvent der Deutschen Gesllschaft für Kinder- und Jugendmedizin, Schwalmstadt-Treysa, Deutschland
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16
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Alghamdi F, Roth C, Jatana KR, Elmaraghy CA, Rice J, Tobias JD, Thung AK. Opioid-Sparing Anesthetic Technique for Pediatric Patients Undergoing Adenoidectomy: A Pilot Study. J Pain Res 2020; 13:2997-3004. [PMID: 33239908 PMCID: PMC7682613 DOI: 10.2147/jpr.s281275] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/11/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION An opioid-sparing anesthetic involves a multi-modal technique with non-opioid medications targeting different analgesic pathways. Such techniques may decrease adverse effects related to opioids. These techniques may be considered in patients at higher risk for opioid-related adverse effects including obstructive sleep apnea or sleep disordered breathing. METHODS A prospective, pilot study was performed in 10 patients (3-8 years of age), presenting for adenoidectomy. The perioperative regimen included oral dextromethorphan (1 mg/kg) and acetaminophen (15 mg/kg) plus single boluses of intraoperative dexmedetomidine (0.5 μg/kg) and ketamine (0.5 mg/kg). Pain scores were assessed in the post anesthesia care unit (PACU) using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Patients with a pain score >4 received fentanyl as needed. PACU time, pain scores, and parent satisfaction were recorded. Postoperatively, patients were instructed to use oral acetaminophen or ibuprofen every 6 hours as needed for pain. RESULTS The study cohort included 10 patients, 3-8 years of age. All patients had opioid-free anesthetic care. PACU time ranged from 24 to 102 minutes (median: 56 minutes). FLACC pain scores were 0 for all PACU assessments. Nine patients were discharged home and 1 patient had a planned overnight admission. Following hospital discharge, the pain scores were satisfactory during the 72-hour study period and 90% of the patients' guardians were satisfied or highly satisfied with their child's pain control. CONCLUSION This opioid-sparing approach provided safe and effective pain control as well as parental satisfaction following adenoidectomy in children. Additional prospective studies are needed to determine whether this regimen is effective in a larger cohort of patients with and for other otolaryngology procedures.
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Affiliation(s)
- Faris Alghamdi
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Catherine Roth
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Kris R Jatana
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children’s Hospital and the Ohio State University, Columbus, OH, USA
| | - Charles A Elmaraghy
- Department of Otolaryngology and Head & Neck Surgery, Nationwide Children’s Hospital and the Ohio State University, Columbus, OH, USA
| | - Julie Rice
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
| | - Arlyne K Thung
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH, USA
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17
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Coté CJ. Obstructive sleep apnoea and polymorphisms: implications for anaesthesia care. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s2.2513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With a worldwide obesity pandemic, the incidence of obstructive sleep apnoea (OSA) is increasing; obesity is the most significant risk factor in children. Increasing evidence suggests that OSA is in part mediated through markers of inflammation. Systemic and pulmonary hypertension, right ventricular hypertrophy, prediabetes, and other conditions are common. Adenotonsillectomy improves only ~70% of children; 30% require other interventions, e.g. weight loss programs. The gold standard for diagnosis is a sleep-polysomnogram which are expensive and not readily available. The McGill oximetry score (saw-tooth desaturations during obstruction and arousal) is more cost-effective.
Repeated episodes of desaturation alter the opioid receptors such that analgesia is achieved at much lower levels of opioid than in patients undergoing the same procedure but without OSA. This response is of great concern because a standard dose of opioids may be a relative overdose.
Polymorphism variations in cytochrome CYP2D6 have major effects upon drug efficacy and side effects. Codeine, hydrocodone, oxycodone, and tramadol are all prodrugs that require CYP2D6 for conversion to the active compound. CYP2D6 is quite variable and patients can be divided into 4 classes: For codeine for example, poor metaboliser (PM) have virtually no conversion to morphine, intermediate metabolisers (IM) have some conversion to morphine, extensive metabolisers (EM) have a normal rate of conversion to morphine, and ultra-rapid metabolisers (RM) convert excessive amounts of codeine to morphine. Such variations result in some patients achieving no analgesia because there is reduced conversion to the active moiety whereas others convert an excessive amount of drug to the active compound thus resulting in relative or actual overdose despite appropriate dosing.
Thus, OSA patients may have both opioid sensitivity due to recurrent desaturations and altered drug metabolism resulting in higher than intended blood levels of opioid. OSA patients should only receive one-third to half the usual dose of opioid. In those under the age of six, an effort should be made to avoid opioids altogether and use opioid sparing techniques such as alternating acetaminophen and ibuprofen.
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18
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Dalesio NM, Lee CKK, Hendrix CW, Kerns N, Hsu A, Clarke W, Collaco JM, McGrath-Morrow S, Yaster M, Brown RH, Schwartz AR. Effects of Obstructive Sleep Apnea and Obesity on Morphine Pharmacokinetics in Children. Anesth Analg 2020; 131:876-884. [PMID: 31688081 DOI: 10.1213/ane.0000000000004509] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obesity increases susceptibility to chronic pain, increases metabolism, and is associated with obstructive sleep apnea syndrome (OSAS), all which can complicate perioperative pain management of patients. In addition, obesity and OSAS can cause elevation of the adipose-derived hormone leptin, which increases metabolism. We hypothesized that obesity along with sleep apnea and leptin independently enhance morphine pharmacokinetics. METHODS Children 5-12 years of age who were presenting for surgery were administered a morphine dose of 0.05 mg/kg. Blood was collected at baseline and at subsequent preset times for pharmacokinetic analysis of morphine and its metabolites. Three groups were studied: a nonobese group with severe OSAS, an obese group with severe OSAS, and a control group. RESULTS Thirty-four patients consisting of controls (n = 16), nonobese/OSAS (n = 8), and obese/OSAS (n = 10) underwent analysis. The obese/OSAS group had a higher dose-adjusted mean maximum morphine concentration (CMAX) over 540 minutes compared to the controls (P < .001) and those with only OSAS (P = .014). The obese/OSAS group also had lower volume of distribution (Vd) when compared to OSAS-only patients (P = .007). In addition, those in the obese/OSAS group had a higher morphine 3-glucuronide (M3G) maximum concentration (P = .012) and a higher ratio of M3G to morphine than did the control group (P = .011). Time to maximum morphine 6-glucuronide (M6G) concentration was significantly lower in both nonobese/OSAS and obese/OSAS groups than in the control group (P < .005). C-reactive protein (CRP), interleukin (IL)-10, and leptin were all higher in the obese/OSAS group than in controls (P = .004, 0.026, and <0.001, respectively), and compared to OSAS-only patients, CRP (P = .013) and leptin (P = .002) levels were higher in the obese/OSAS group. CONCLUSIONS The combination of obesity and OSAS was associated with an increase in morphine metabolism compared with that in normal-weight controls. Our previous study in mice demonstrated that obesity from leptin deficiency decreased morphine metabolism, but that metabolism normalized after leptin replacement. Leptin may be a cause of the increased morphine metabolism observed in obese patients.
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Affiliation(s)
- Nicholas M Dalesio
- From the Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carlton K K Lee
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Craig W Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nikole Kerns
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron Hsu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William Clarke
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph M Collaco
- Division of Pediatric Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon McGrath-Morrow
- Division of Pediatric Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Myron Yaster
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Robert H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alan R Schwartz
- From the Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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19
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Ji KSY, Greene NH, Eapen RJ, Commesso E, Raynor EM. Pre- Versus Post-Tonsillectomy Intraoperative Bupivacaine Injection in the Pediatric Population: An Age- and Surgical Indication-Stratified Analysis. EAR, NOSE & THROAT JOURNAL 2020; 101:518-525. [PMID: 33095665 DOI: 10.1177/0145561320968926] [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] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Postoperative respiratory depression is of concern in children undergoing adenotonsillectomy receiving postoperative opioids and may be mitigated with intraoperative bupivacaine. This study aims to compare the impact of bupivacaine on postoperative pain and sedation in various pediatric age and surgical indication subgroups. METHODS This is a case series with chart review of 181 patients <18 years old undergoing adenotonsillectomy at a tertiary care center (2013-2016). Postoperative outcomes were compared between those who received intraoperative bupivacaine before (pre-tonsillectomy) or after (post-tonsillectomy) tonsil removal and those who did not (none) using χ2 test and analysis of variance. Subanalysis was performed after stratifying into age and surgical indication subgroups. RESULTS Ninety-eight patients were included in the pre-tonsillectomy group, 47 in the post-tonsillectomy group, and 36 in the none group. The number of postanesthesia care unit opioid doses (P = .159) and pain scores at arrival (P = .362) or discharge (P = .255) were not significantly different between treatment groups overall. Among 0- to 5-year-olds, pre-tonsillectomy injection was associated with lowest mean (SD) discharge pain score of 0.55 (1.29) pre-tonsillectomy versus 0.71 (1.37) post-tonsillectomy versus 2 (1.63) none group (P = .004). Among 12- to 17-year-olds, no injection was associated with lowest mean (SD) discharge pain score of 2.33 (0.52) pre-tonsillectomy versus 5 (2.65) post-tonsillectomy versus 1.63 (1.60) none group (P = .020). Injection in patients with obstructive sleep apnea and/or sleep-disordered breathing did not improve postoperative outcomes. CONCLUSION Intraoperative bupivacaine may improve pain scores in younger pediatric populations, though it may not impact the amount of postoperative opioid use. Prospective analysis with a larger sample size is warranted to better outline opioid usage and pain control in this group.
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Affiliation(s)
- Keven S Y Ji
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Nathan H Greene
- Division of Pediatrics, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Rose J Eapen
- South Bay Pediatric Otolaryngology, Manhattan Beach, CA, USA
| | - Emily Commesso
- Department of Head and Neck Surgery & Communication Sciences, Duke University Hospital, Durham, NC, USA
| | - Eileen M Raynor
- Department of Head and Neck Surgery & Communication Sciences, Duke University Hospital, Durham, NC, USA
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20
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Blackshaw H, Springford LR, Zhang LY, Wang B, Venekamp RP, Schilder AG. Tonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children. Cochrane Database Syst Rev 2020; 4:CD011365. [PMID: 32347984 PMCID: PMC7193676 DOI: 10.1002/14651858.cd011365.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Obstructive sleep-disordered breathing (oSDB) is a condition encompassing breathing problems when asleep due to upper airway obstruction. In children, hypertrophy of the tonsils and/or adenoids is thought to be the commonest cause. As such, (adeno)tonsillectomy has long been the treatment of choice. A rise in partial removal of the tonsils over the last decade is due to the hypothesis that tonsillotomy is associated with lower postoperative morbidity and fewer complications. OBJECTIVES To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications. SEARCH METHODS We searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 22 July 2019. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing the effectiveness of (adeno)tonsillectomy with (adeno)tonsillotomy in children aged 2 to 16 years with oSDB. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods and assessed the certainty of the evidence for our pre-defined outcomes using GRADE. Our primary outcomes were disease-specific quality of life, peri-operative blood loss and the proportion of children requiring postoperative medical intervention (with or without hospitalisation). Secondary outcomes included postoperative pain, return to normal activity, recurrence of oSDB symptoms as a result of tonsil regrowth and reoperation rates. MAIN RESULTS We included 22 studies (1984 children), with predominantly unclear or high risk of bias. Three studies used polysomnography as part of their inclusion criteria. Follow-up duration ranged from six days to six years. Although 19 studies reported on some of our outcomes, we could only pool the results from a few due both to the variety of outcomes and the measurement instruments used, and an absence of combinable data. Disease-specific quality of life Four studies (540 children; 484 (90%) analysed) reported this outcome; data could not be pooled due to the different outcome measurement instruments used. It is very uncertain whether there is any difference in disease-specific quality of life between the two surgical procedures in the short (0 to 6 months; 3 studies, 410 children), medium (7 to 13 months; 2 studies, 117 children) and long term (13 to 24 months; 1 study, 67 children) (very low-certainty evidence). Peri-operative blood loss We are uncertain whether tonsillotomy reduces peri-operative blood loss by a clinically meaningful amount (mean difference (MD) 14.06 mL, 95% CI 1.91 to 26.21 mL; 8 studies, 610 children; very low-certainty evidence). In sensitivity analysis (restricted to three studies with low risk of bias) there was no evidence of a difference between the groups. Postoperative complications requiring medical intervention (with or without hospitalisation) The risk of postoperative complications in the first week after surgery was probably lower in children who underwent tonsillotomy (4.9% versus 2.6%, risk ratio (RR) 1.75, 95% CI 1.06 to 2.91; 16 studies, 1416 children; moderate-certainty evidence). Postoperative pain Eleven studies (1017 children) reported this outcome. Pain was measured using various scales and scored by either children, parents, clinicians or study personnel. When considering postoperative pain there was little or no difference between tonsillectomy and tonsillotomy at 24 hours (10-point scale) (MD 1.09, 95% CI 0.88 to 1.29; 4 studies, 368 children); at two to three days (MD 0.93, 95% CI -0.14 to 2.00; 3 studies, 301 children); or at four to seven days (MD 1.07, 95% CI -0.40 to 2.53; 4 studies, 370 children) (all very low-certainty evidence). In sensitivity analysis (restricted to studies with low risk of bias), we found no evidence of a difference in mean pain scores between groups. Return to normal activity Tonsillotomy probably results in a faster return to normal activity. Children who underwent tonsillotomy were able to return to normal activity four days earlier (MD 3.84 days, 95% CI 0.23 to 7.44; 3 studies, 248 children; moderate-certainty evidence). Recurrence of oSDB and reoperation rates We are uncertain whether there is a difference between the groups in the short (RR 0.26, 95% CI 0.03 to 2.22; 3 studies, 186 children), medium (RR 0.35, 95% CI 0.04 to 3.23; 4 studies, 206 children) or long term (RR 0.21 95% CI 0.01 to 4.13; 1 study, 65 children) (all very low-certainty evidence). AUTHORS' CONCLUSIONS For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. More robust data from high-quality cohort studies, which may be more appropriate for detecting differences in less common events in the long term, are required to inform guidance on which tonsil surgery technique is best for children with oSDB requiring surgery.
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Affiliation(s)
- Helen Blackshaw
- evidENT, Ear Institute, University College London, London, UK
- National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, UK
| | - Laurie R Springford
- evidENT, Ear Institute, University College London, London, UK
- National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, UK
| | - Lai-Ying Zhang
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Betty Wang
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Anne Gm Schilder
- evidENT, Ear Institute, University College London, London, UK
- National Institute of Health Research, University College London Hospitals Biomedical Research Centre, London, UK
- Julius Center for Health Sciences and Primary Care & Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Smith DF, He S, Peddireddy NS, Vairavan Manickam P, Heubi CH, Shott SR, Cohen AP, Ishman SL. Effectiveness of pediatric drug-induced sleep endoscopy for REM-predominant obstructive sleep apnea. Sleep Breath 2020; 24:1705-1713. [PMID: 32277395 DOI: 10.1007/s11325-020-02056-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVES Because dexmedetomidine (DEX)-induced sedation mimics non-rapid eye movement (NREM) sleep, its utility in sedating children with REM-predominant disease is unclear. We sought to determine the effectiveness of pediatric drug-induced sleep endoscopy (DISE) using DEX and ketamine for children with REM-predominant OSA, specifically whether or not at least one site of obstruction could be identified. METHODS A retrospective case series of children without tonsillar hypertrophy undergoing DISE at a tertiary pediatric hospital from 10/2013 through 9/2015 who underwent subsequent surgery to address OSA with polysomnography (PSG) before and after. RESULTS We included 56 children, mean age 5.6±5.4 years, age range 0.1-17.4 years, mean BMI 20.3±7.4 kg/m2 (76±29 percentile). At least one site of obstruction was identified in all patients, regardless of REM- or NREM-predominance. The mean obstructive apnea-hypopnea index (oAHI) improved (12.6 ± 10.7 to 9.0 ± 14.0 events/h) in children with REM-predominant (P = 0.013) and NREM-predominant disease (21.3 ± 18.9 to 10.3 ± 16.2 events/h) (P = 0.008). The proportion of children with a postoperative oAHI < 5 was 53% and 55% for REM- and NREMpredominant OSA, respectively. Unlike children with NREM-predominant disease, children with REM-predominant disease had significant improvement in the mean saturation nadir (P < 0.001), total sleep time (P = 0.006), and sleep efficiency (P = 0.015). CONCLUSIONS For children with OSA without tonsillar hypertrophy, DISE using DEX/ketamine was useful to predict at least one site of obstruction, even for those with REM-predominant OSA. DISE-directed outcomes resulted in significant improvements in mean oAHI, total sleep time, sleep efficiency, saturation nadir, and the proportion with oAHI < 5, after surgery for some children with REM-predominant disease.
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Affiliation(s)
- David F Smith
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shan He
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA
- Department of Otolaryngology, Shanghai Children's Hospital Affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Nithin S Peddireddy
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA
| | - P Vairavan Manickam
- Department of Otolaryngology-Head and Neck Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Christine H Heubi
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sally R Shott
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aliza P Cohen
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA
| | - Stacey L Ishman
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA.
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC 2018, Cincinnati, OH, 45229-2018, USA.
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Melesse DY, Mekonnen ZA, Kassahun HG, Chekol WB. Evidence based perioperative optimization of patients with obstructive sleep apnea in resource limited areas: A systematic review. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019; 160:S1-S42. [PMID: 30798778 DOI: 10.1177/0194599818801757] [Citation(s) in RCA: 272] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This update of a 2011 guideline developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations on the pre-, intra-, and postoperative care and management of children 1 to 18 years of age under consideration for tonsillectomy. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil, including its capsule, by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Tonsillectomy is one of the most common surgical procedures in the United States, with 289,000 ambulatory procedures performed annually in children <15 years of age based on the most recent published data. This guideline is intended for all clinicians in any setting who interact with children who may be candidates for tonsillectomy. PURPOSE The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing children under consideration for tonsillectomy and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to educate clinicians, patients, and/or caregivers regarding the indications for tonsillectomy and the natural history of recurrent throat infections. Additional goals include the following: optimizing the perioperative management of children undergoing tonsillectomy, emphasizing the need for evaluation and intervention in special populations, improving the counseling and education of families who are considering tonsillectomy for their children, highlighting the management options for patients with modifying factors, and reducing inappropriate or unnecessary variations in care. Children aged 1 to 18 years under consideration for tonsillectomy are the target patient for the guideline. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of nursing, anesthesiology, consumers, family medicine, infectious disease, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. KEY ACTION STATEMENTS The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should recommend watchful waiting for recurrent throat infection if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years. (2) Clinicians should administer a single intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. (3) Clinicians should recommend ibuprofen, acetaminophen, or both for pain control after tonsillectomy. The guideline update group made recommendations for the following KASs: (1) Clinicians should assess the child with recurrent throat infection who does not meet criteria in KAS 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of >1 peritonsillar abscess. (2) Clinicians should ask caregivers of children with obstructive sleep-disordered breathing and tonsillar hypertrophy about comorbid conditions that may improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. (3) Before performing tonsillectomy, the clinician should refer children with obstructive sleep-disordered breathing for polysomnography if they are <2 years of age or if they exhibit any of the following: obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (4) The clinician should advocate for polysomnography prior to tonsillectomy for obstructive sleep-disordered breathing in children without any of the comorbidities listed in KAS 5 for whom the need for tonsillectomy is uncertain or when there is discordance between the physical examination and the reported severity of oSDB. (5) Clinicians should recommend tonsillectomy for children with obstructive sleep apnea documented by overnight polysomnography. (6) Clinicians should counsel patients and caregivers and explain that obstructive sleep-disordered breathing may persist or recur after tonsillectomy and may require further management. (7) The clinician should counsel patients and caregivers regarding the importance of managing posttonsillectomy pain as part of the perioperative education process and should reinforce this counseling at the time of surgery with reminders about the need to anticipate, reassess, and adequately treat pain after surgery. (8) Clinicians should arrange for overnight, inpatient monitoring of children after tonsillectomy if they are <3 years old or have severe obstructive sleep apnea (apnea-hypopnea index ≥10 obstructive events/hour, oxygen saturation nadir <80%, or both). (9) Clinicians should follow up with patients and/or caregivers after tonsillectomy and document in the medical record the presence or absence of bleeding within 24 hours of surgery (primary bleeding) and bleeding occurring later than 24 hours after surgery (secondary bleeding). (10) Clinicians should determine their rate of primary and secondary posttonsillectomy bleeding at least annually. The guideline update group made a strong recommendation against 2 actions: (1) Clinicians should not administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. (2) Clinicians must not administer or prescribe codeine, or any medication containing codeine, after tonsillectomy in children younger than 12 years. The policy level for the recommendation about documenting recurrent throat infection was an option: (1) Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and ≥1 of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus. DIFFERENCES FROM PRIOR GUIDELINE (1) Incorporating new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply. (2) There were 1 new clinical practice guideline, 26 new systematic reviews, and 13 new randomized controlled trials included in the current guideline update. (3) Inclusion of 2 consumer advocates on the guideline update group. (4) Changes to 5 KASs from the original guideline: KAS 1 (Watchful waiting for recurrent throat infection), KAS 3 (Tonsillectomy for recurrent infection with modifying factors), KAS 4 (Tonsillectomy for obstructive sleep-disordered breathing), KAS 9 (Perioperative pain counseling), and KAS 10 (Perioperative antibiotics). (5) Seven new KASs: KAS 5 (Indications for polysomnography), KAS 6 (Additional recommendations for polysomnography), KAS 7 (Tonsillectomy for obstructive sleep apnea), KAS 12 (Inpatient monitoring for children after tonsillectomy), KAS 13 (Postoperative ibuprofen and acetaminophen), KAS 14 (Postoperative codeine), and KAS 15a (Outcome assessment for bleeding). (6) Addition of an algorithm outlining KASs. (7) Enhanced emphasis on patient and/or caregiver education and shared decision making.
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Affiliation(s)
| | | | - Stacey L Ishman
- 3 Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Sarah Coles
- 5 University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Sandra A Finestone
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | | | - Terri Giordano
- 8 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Tae W Kim
- 10 University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Robin M Lloyd
- 11 Mayo Clinic Center for Sleep Medicine, Rochester, Minnesota, USA
| | | | - Stanford T Shulman
- 13 Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David L Walner
- 14 Advocate Children's Hospital, Park Ridge, Illinois, USA
| | - Sandra A Walsh
- 6 Consumers United for Evidence-based Healthcare, Fredericton, New Brunswick, Canada
| | - Lorraine C Nnacheta
- 15 Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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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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Teplitzky TB, Pereira KD, Isaiah A. Echocardiographic screening in children with very severe obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2019; 126:109626. [PMID: 31421356 DOI: 10.1016/j.ijporl.2019.109626] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/03/2019] [Accepted: 08/04/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE (i) To determine the prevalence of echocardiographic abnormalities in children with very severe OSA defined by an apnea hypopnea index (AHI) ≥ 30 events/hour. (ii) To test the hypothesis that polysomnographic parameters predict echocardiographic variables in this population. METHODS Children aged 1-17 years presenting with polysomnography demonstrating an AHI ≥30 and referred for pre-operative echocardiography performed within the 6 months prior to tonsillectomy and adenoidectomy (T&A), over a two-year period (January 1, 2016 to December 31, 2018) were evaluated. The exclusion criteria were the presence of (i) unrepaired congenital cardiac disease, (ii) tracheostomy, (iii) poorly controlled asthma, or (iv) neuromuscular disorder. The prevalence of echocardiographic abnormalities was determined for the study population. The impact of the severity of OSA on echocardiographic parameters was evaluated using Student's t-test. The relationships between polysomnographic variables and biventricular function as well as pulmonary hemodynamics were measured. A penalized regression model was used to identify the contributions of polysomnographic variables to each echocardiographic parameter by mitigating inter-variable relationships. P < .05 was considered significant. RESULTS Eighty-nine children were screened, of whom 47 were included for analysis. The mean age was 68.8 months [95% confidence interval, 56.0 to 81.6]. Thirty-three (70.2%) were boys. Twenty (42.6%) were obese. All children had normal echocardiograms. The differences in echocardiographic variables between children grouped by the severity of OSA were not statistically significant (P: 0.18-0.98). Polysomnographic variables predicted only 4 out of 13 studied echocardiographic parameters. CONCLUSIONS Pre-operative echocardiography did not identify significant abnormalities in children with very severe OSA. Majority of the echocardiographic variables were not predicted by polysomnographic parameters. This study demonstrates the limited benefit associated with routine echocardiographic screening of children with very severe OSA solely based on polysomnographic indices.
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Affiliation(s)
- Taylor B Teplitzky
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Kevin D Pereira
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland Medical Center, Baltimore, MD, USA; Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amal Isaiah
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland Medical Center, Baltimore, MD, USA; Department of Otorhinolaryngology - Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
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Zhang Y, Yang Y, Barnard M, Bentley JP, Ramachandran S. Opioid Use for Treatment of Acute Pain Among Children and Adolescents Enrolled in the Mississippi Medicaid Program. J Pharm Pract 2019; 34:558-566. [PMID: 31665970 DOI: 10.1177/0897190019883767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Abuse of opioids among children and adolescents has become a major public concern in the United States. Understanding the epidemiology of opioid use in this vulnerable population is critical to address opioid abuse. OBJECTIVE The aim of this study is to characterize opioid use for the treatment of acute pain among children and adolescents enrolled in Mississippi Medicaid and to determine the effects of related clinical factors (ie, mental health disorders and obstructive sleep apnea [OSA] on patterns of opioid use. METHODS A retrospective cohort study was conducted using the Mississippi Medicaid administrative claims data from October 2015 through December 2017. We examined the proportion of children and adolescents less than 21 years of age using opioids within 7 days following any qualifying acute pain episode, as well as the difference in opioid use patterns between individuals with various demographic and clinical characteristics. RESULTS Over 5% of the eligible population received opioids within 7 days of a qualifying pain episode. The majority received schedule II or schedule III to IV short-acting opioids. There was no significant difference in opioid use for acute pain between individuals with and without a mental health disorder. Opioid use for acute pain was significantly more likely among those with a history of OSA than those without OSA. CONCLUSION This study characterizes the nature and patterns of opioid use among children and adolescents with acute pain. Further research is needed to understand the role of clinical and other demographic factors in the prescribing of opioids for acute pain in this population.
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Affiliation(s)
- Yiqiao Zhang
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
| | - Yi Yang
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
| | - Marie Barnard
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
| | - John P Bentley
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
| | - Sujith Ramachandran
- Department of Pharmacy Administration, School of Pharmacy, 8083University of Mississippi, MS, USA
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Montana MC, Juriga L, Sharma A, Kharasch ED. Opioid Sensitivity in Children with and without Obstructive Sleep Apnea. Anesthesiology 2019; 130:936-945. [DOI: 10.1097/aln.0000000000002664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Opioids are a mainstay of perioperative analgesia. Opioid use in children with obstructive sleep apnea is challenging because of assumptions for increased opioid sensitivity and assumed risk for opioid-induced respiratory depression compared to children without obstructive sleep apnea. These assumptions have not been rigorously tested. This investigation tested the hypothesis that children with obstructive sleep apnea have an increased pharmacodynamic sensitivity to the miotic and respiratory depressant effects of the prototypic μ-opioid agonist remifentanil.
Methods
Children (8 to 14 yr) with or without obstructive sleep apnea were administered a 15-min, fixed-rate remifentanil infusion (0.05, 0.1, or 0.15 μg · kg-1 · min-1). Each dose group had five patients with and five without obstructive sleep apnea. Plasma remifentanil concentrations were measured by tandem liquid chromatography mass spectrometry. Remifentanil effects were measured via miosis, respiratory rate, and end-expired carbon dioxide. Remifentanil pharmacodynamics (miosis vs. plasma concentration) were compared in children with or without obstructive sleep apnea.
Results
Remifentanil administration resulted in miosis in both non-obstructive sleep apnea and obstructive sleep apnea patients. No differences in the relationship between remifentanil concentration and miosis were seen between the two groups at any of the doses administered. The administered dose of remifentanil did not affect respiratory rate or end-expired carbon dioxide in either group.
Conclusions
No differences in the remifentanil concentration–miosis relation were seen in children with or without obstructive sleep apnea. The dose and duration of remifentanil administered did not alter ventilatory parameters in either group.
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Affiliation(s)
- Michael C. Montana
- From the Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri (M.C.M., L.J., A.S., E.D.K.); and the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (E.D.K.)
| | - Lindsay Juriga
- From the Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri (M.C.M., L.J., A.S., E.D.K.); and the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (E.D.K.)
| | - Anshuman Sharma
- From the Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri (M.C.M., L.J., A.S., E.D.K.); and the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (E.D.K.)
| | - Evan D. Kharasch
- From the Department of Anesthesiology, Washington University in St. Louis, School of Medicine, St. Louis, Missouri (M.C.M., L.J., A.S., E.D.K.); and the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina (E.D.K.)
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Perioperative interdisciplinary approach for reduction of opioid use in pediatric tonsillectomy: Protocol using dexmedetomidine and bupivicaine as adjunct agents. Am J Otolaryngol 2019; 40:382-388. [PMID: 30803808 DOI: 10.1016/j.amjoto.2019.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/24/2019] [Accepted: 02/18/2019] [Indexed: 11/24/2022]
Abstract
IMPORTANCE Pediatric tonsillectomy is a common procedure now being performed most often for patients with obstructive sleep apnea, which has been associated with increased sensitivity to the respiratory side effects of opioid medications. This study investigates a strategy to decrease the use of opiate medications in a particularly vulnerable population. OBJECTIVE Describe an interdisciplinary approach between Otolaryngologists and Anesthesiologists to decrease opiate use in tonsillectomy patients. Demonstrate safety of this protocol. Evaluate the effect of the protocol on intraoperative need for opiate medications and inhaled anesthetic use. Perform cost analysis of the protocol. DESIGN Retrospective case-control study with cost analysis. SETTING Tertiary Care Hospital. PARTICIPANTS Pediatric patients undergoing tonsillectomy at a tertiary care hospital. INTERVENTIONS Preoperative and intraoperative dexmedetomidine with local bupivacaine injection into the tonsillar fossa. MEASURES Intraoperative need for sevoflurane, opiate, and propofol. Post-operative pain scores, and utilization of post-operative opiate, acetaminophen, and ibuprofen pain medications. Post-operative adverse events. Cost analysis of protocol. RESULTS This protocol led to a decrease in intraoperative opiate use by 49.6%, a decrease in intraoperative sevofluorane use by 18%, and a lower reported maximum post-operative pain score without any increase in adverse events. The protocol added a small increase in medication cost of $4.07 to each procedure. CONCLUSION The use of dexmedetomidine and local anesthetic in pediatric tonsillectomy is a safe and effective protocol that allows for the reduction of opiate use and improved post-operative pain control. KEY POINTS Question: Can the combination of dexmedetomidine and infiltration of local anesthetic reduce overall opioid use for peediatric patients undergoing tonsillectomy? FINDINGS In this case-control study, use of dexmedetomidine and local anesthetic injected into the tonsillar fossa led to a decrease in intraoperative opiate use by 49.6%, a decrease in intraoperative sevofluorane use by 18%, and a lower reported maximum pain score without an increase in adverse events. Meaning: Use of dexmedetomidine and local anesthetic as anesthetic adjuncts may help reduce need for intraoperative opiates and decrease the use of volatile anesthetic agents in pediatric tonsillectomy patients, which are undesirable medications in the pediatric population for their respective respiratory depression and potentially neurotoxic side effects.
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Lee SY, Kim JW. Nasopharyngeal Width and Its Association With Sleep-Disordered Breathing Symptoms in Children. Clin Exp Otorhinolaryngol 2019; 12:399-404. [PMID: 30832459 PMCID: PMC6787469 DOI: 10.21053/ceo.2018.01151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 12/26/2018] [Indexed: 01/07/2023] Open
Abstract
Objectives Although adenotonsillar hypertrophy is the main cause of sleep-disordered breathing in children, surrounding anatomic factors, such as the width of the nasopharynx, can affect upper airway patency. However, there have been no reports of the association of nasopharyngeal width with sleep-disordered breathing in children. This study was undertaken to measure nasopharyngeal width in children undergoing adenotonsillectomy for sleep-disordered breathing and to investigate the clinical implications of this factor. Methods This was a retrospective study with a follow-up period of 1 year, performed at a tertiary referral center. We reviewed the operative records of children who underwent adenotonsillectomy at our center for symptoms of sleep-disordered breathing, such as snoring, apnea, and mouth breathing. The nasopharyngeal width was measured immediately before adenotonsillectomy, which was performed under general anesthesia with a microscopy-assisted mirror view. Adenotonsillar hypertrophy was graded on a four-point scale, and symptoms of sleep-disordered breathing were evaluated by using the Korean version of the Obstructive Sleep Apnea-18 questionnaire before and after surgery. The relationships between the average nasopharyngeal width and patient age and sex, adenotonsillar hypertrophy, and the Korean version of the Obstructive Sleep Apnea-18 score were analyzed. Results The study included 549 children (343 boys) with a mean age of 6.0 years (range, 2 to 11 years). The average nasopharyngeal width was 11.9 mm (range, 7.0 to 18.0 mm) and increased with age (range, 11.2 to 13.3; β=0.264; P<0.001). At 1 year after surgery, children with a greater nasopharyngeal width at the time of surgery exhibited additional improvements in symptoms of obstruction relative to those at 1 month after surgery. Conclusion The average nasopharyngeal width in children is approximately 11.9 mm and exhibits a slight increase with age. The width of the nasopharynx may be a factor associated with the degree of improvement in symptoms of sleep-disordered breathing after adenotonsillectomy.
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Affiliation(s)
- Sang-Youp Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jeong-Whun Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Abstract
The article reviews frequently encountered preoperative concerns with a goal of minimizing complications during administration of pediatric anesthesia. It is written with general anesthesiologists in mind and provides a helpful overview of concerns for pediatric patient preparation for routine and nonemergent procedures or interventions. It covers unique topics for the pediatric population, including gestational age, respiratory and cardiovascular concerns, fasting guidelines, and management of preoperative anxiety, as well as the current hot topic of the potential neurotoxic effects of anesthetics on the developing brain.
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Affiliation(s)
- Allison Basel
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Anaesthesia, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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Lejus C, Orliaguet G, Servin F, Dadure C, Michel F, Brasher C, Dahmani S. Peri-operative management of overweight and obese children and adolescents. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 1:311-322. [PMID: 30169186 DOI: 10.1016/s2352-4642(17)30090-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/27/2017] [Accepted: 08/15/2017] [Indexed: 12/11/2022]
Abstract
Obesity has become endemic, even in children. Systemic complications associated with obesity include metabolic syndrome, cardiovascular disease, and respiratory compromise. These comorbidities require adequate investigation, targeted optimisation, and, if surgery is required, specific management during the peri-operative period. Specific peri-operative strategies should be used for paediatric patients who are overweight or obese to prevent postoperative complications, and optimising the respiratory function during surgery is particularly crucial. This Review aims to provide up-to-date information on peri-operative management for physicians who are caring for children and adolescents (usually younger than 18 years) who are overweight or obese undergoing surgery, including bariatric surgery. We have particularly focussed on the physiological consequences of obesity-namely, obstructive sleep apnoea, respiratory compromise, and pharmacological considerations.
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Affiliation(s)
- Corinne Lejus
- Department of Anaesthesia and Intensive care, Hôtel Dieu Hospital, Nantes, France
| | - Gilles Orliaguet
- Department of Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Necker-Enfants Malades Hospital, Paris, France; EA08 Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, Paris-Descartes and Paris Descartes University (Paris V), PRES Paris Sorbonne Cité, Paris, France
| | - Frederique Servin
- Department of Anaesthesia and Intensive Care, Assistance Publique Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Christophe Dadure
- Department of Anaesthesia and Intensive care, Lapeyronie University Hospital, Montpellier, France; Institut de Neuroscience de Montpellier, Unité INSERM, Montpellier, France
| | - Fabrice Michel
- Department of Anaesthesia and Intensive Care, La Timone Hospital, Marseille, France; Espace Ethique Méditerranéen, Aix-Marseille Université, Hôpital Timone Adulte, Marseille, France
| | - Christopher Brasher
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, VIC, Australia; Anesthesia and Pain Management Research Group, Murdoch Children's Research Institute, VIC, Australia
| | - Souhayl Dahmani
- DHU PROTECT, INSERM U1141, Paris, France; Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Assistance Publique Hôpitaux de Paris, Paris Diderot University, PRES Paris Sorbonne Cité, Paris, France.
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Ruda JM, Payne L, May A, Splaingard M, Lemle S, Jatana KR. Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families. Otolaryngol Head Neck Surg 2018; 160:791-798. [DOI: 10.1177/0194599818789116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner. Methods Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days. Results Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period ( P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children’s study results. Discussion Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner. Implications for Practice With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea.
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Affiliation(s)
- James M. Ruda
- Department of Pediatric Otolaryngology–Head and Neck Surgery, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Linda Payne
- Department of Pediatric Otolaryngology–Head and Neck Surgery, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Anne May
- Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Department of Sleep Medicine and Pulmonology, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Mark Splaingard
- Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Department of Sleep Medicine and Pulmonology, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Stephanie Lemle
- Department of Quality Improvement, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Kris R. Jatana
- Department of Pediatric Otolaryngology–Head and Neck Surgery, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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Chidambaran V, Tewari A, Mahmoud M. Anesthetic and pharmacologic considerations in perioperative care of obese children. J Clin Anesth 2018; 45:39-50. [DOI: 10.1016/j.jclinane.2017.12.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
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Paediatric obstructive sleep apnoea: is our operative management evidence-based? The Journal of Laryngology & Otology 2018; 132:293-298. [PMID: 29463325 DOI: 10.1017/s002221511800021x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Despite the plethora of publications on the subject of paediatric obstructive sleep apnoea, there seems to be wide variability in the literature and in practice, regarding recourse to surgery, the operation chosen, the benefits gained and post-operative management. This may reflect a lack of high-level evidence. METHODS A systematic review of four significant controversies in paediatric ENT was conducted from the available literature: tonsillectomy versus tonsillotomy, focusing on the evidence base for each; anaesthetic considerations in paediatric obstructive sleep apnoea surgery; the objective evidence for the benefits of surgical treatment for obstructive sleep apnoea; and the medical treatment options for residual obstructive sleep apnoea after surgical treatment. RESULTS AND CONCLUSION There are many gaps in the evidence base for the surgical correction of obstructive sleep apnoea. There is emerging evidence favouring subtotal tonsillectomy. There is continuing uncertainty around the prediction of the level of post-operative care that any individual child might require. The long-term benefit of surgical correction is a particularly fertile ground for further research.
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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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Smith DF, Spiceland CP, Ishman SL, Engorn BM, Donohue C, Park PS, Benke JR, Frazee T, Brown RH, Dalesio NM. Admission Criteria for Children With Obstructive Sleep Apnea After Adenotonsillectomy: Considerations for Cost. J Clin Sleep Med 2017; 13:1463-1472. [PMID: 29117883 DOI: 10.5664/jcsm.6850] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 09/28/2017] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Postoperative respiratory complications (PRCs) are common among children with obstructive sleep apnea (OSA) after adenotonsillectomy. We analyzed postoperative admission guidelines to determine which optimally balanced patient safety and cost. METHODS Retrospective study of children aged 12 years or younger undergoing adenotonsillectomy for OSA after polysomnography at a tertiary academic care center over 2 years. Demographics, medical History, and hospital course were collected. Advanced Excel modeling was used to assess the number of children with PRCs identified with guideline admission criteria and to validate the significance of these findings in our patient population with logistic regression. RESULTS Six hundred thirty children were included; 116 had documented PRCs. Children with PRCs were younger (P = .024) and more frequently male (P = .012). There were no significant differences in race (P = .411) or obesity (P = .265). More children with PRCs had an apnea-hypopnea index (AHI) > 24 events/h (P < .001). Following guidelines from the American Academy of Pediatrics, American Academy of Otolaryngology - Head and Neck Surgery, and Nationwide Children's Hospital, 82%, 87%, and 99% of children with PRCs would be identified, costing $535,962, $647,165, and $1,053,694 for admission, respectively. Using a non-validated, forced model to refine predictors described in published guidelines, our model would have identified 95% of children with one or more PRCs, with a moderate cost. CONCLUSIONS Current admission guidelines attempt to identify children with OSA at high risk for PRCs after adenotonsillectomy; however, none consider the economic cost to the health care system. We present a comparison of the number of patients identified with PRCs after adenotonsillectomy and the cost of expected admissions using currently published guidelines. COMMENTARY A commentary on this article appears in this issue on page 1371.
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Affiliation(s)
- David F Smith
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Stacey L Ishman
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Branden M Engorn
- Department of Anesthesiology, Division of Pediatric Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christopher Donohue
- Department of Anesthesiology, Division of Pediatric Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Paul S Park
- Department of Anesthesiology, Division of Pediatric Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - James R Benke
- Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tiffany Frazee
- Department of Anesthesiology, Division of Pediatric Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robert H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nicholas M Dalesio
- Department of Anesthesiology, Division of Pediatric Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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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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Consideraciones en el paciente pediátrico con síndrome de apnea/hipopnea obstructiva del sueño (SAHOS): desde la fisiopatología al perioperatorio. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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40
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Considerations in pediatric patients with obstructive sleep apnea/hypopnea syndrome (OSAHS): From physiopathology to the perioperative period. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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41
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Considerations in pediatric patients with obstructive sleep apnea/hypopnea syndrome (OSAHS): From physiopathology to the perioperative period☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201707000-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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De A, Waltuch T, Gonik NJ, Nguyen-Famulare N, Muzumdar H, Bent JP, Isasi CR, Sin S, Arens R. Sleep and Breathing the First Night After Adenotonsillectomy in Obese Children With Obstructive Sleep Apnea. J Clin Sleep Med 2017; 13:805-811. [PMID: 28454600 DOI: 10.5664/jcsm.6620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 03/30/2017] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVES There are few studies measuring postoperative respiratory complications in obese children with obstructive sleep apnea (OSA) undergoing adenotonsillectomy (AT). These complications are further compounded by perioperative medications. Our objective was to study obese children with OSA for their respiratory characteristics and sleep architecture on the night of AT. METHODS This was a prospective study at a tertiary pediatric hospital between January 2009-February 2012. Twenty obese children between 8-17 years of age with OSA and adenotonsillar hypertrophy were recruited. Patients underwent baseline polysomnography (PSG) and AT with or without additional debulking procedures, followed by a second PSG on the night of surgery. Demographic and clinical variables, surgical details, perioperative anesthetics and analgesics, and PSG respiratory and sleep architecture parameters were recorded. Statistical tests included Pearson correlation coefficient for correlation between continuous variables and chi-square and Wilcoxon rank-sum tests for differences between groups. RESULTS Baseline PSG showed OSA with mean obstructive apnea-hypopnea index (oAHI) 27.1 ± 22.9, SpO2 nadir 80.1 ± 7.9%, and sleep fragmentation-arousal index 25.5 ± 22.0. Postoperatively, 85% of patients had abnormal sleep studies similar to baseline, with postoperative oAHI 27.0 ± 34.3 (P = .204), SpO2 nadir, 82.0 ± 8.7% (P = .462), and arousal index, 24.3 ± 24.0 (P = .295). Sleep architecture was abnormal after surgery, showing a significant decrease in REM sleep (P = .003), and a corresponding increase in N2 (P = .017). CONCLUSIONS Obese children undergoing AT for OSA are at increased risk for residual OSA on the night of surgery. Special considerations should be taken for postoperative monitoring and treatment of these children. COMMENTARY A commentary on this article appears in this issue on page 775.
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Affiliation(s)
- Aliva De
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Temima Waltuch
- Department of Pediatrics, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Nathan J Gonik
- Department of Otolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.,CS Mott Children's Hospital, University of Michigan, Anne Arbor, Michigan
| | - Ngoc Nguyen-Famulare
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York.,Department of Anesthesiology, Winthrop-University Hospital, Mineola, New York
| | - Hiren Muzumdar
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York.,Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John P Bent
- Department of Otolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Carmen R Isasi
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York
| | - Sanghun Sin
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Raanan Arens
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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Asimakopoulos P, Pennell DJL, Mamais C, Veitch D, Stafrace S, Engelhardt T. Ultrasonographic assessment of tonsillar volume in children. Int J Pediatr Otorhinolaryngol 2017; 95:1-4. [PMID: 28576514 DOI: 10.1016/j.ijporl.2017.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 01/14/2017] [Accepted: 01/17/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Adenotonsillar hypertrophy in children is the most common anatomical abnormality associated with obstructive sleep apnoea. Perioperative complications associated with adenotonsillectomy are more common in children with severe obstructive sleep apnoea. An objective preoperative method to determine the size of tonsils is missing. This study assessed the validity of ultrasound as a tool for measuring tonsillar size in children. METHODS Single-institution prospective study of twenty-six children aged 2-6 years who underwent elective bilateral tonsillectomy. Trans-cervical ultrasonographic assessment of tonsillar size prior to tonsillectomy operation was performed. We assessed correlation of ultrasonographic and actual tonsillar volume. RESULTS A total of 52 tonsils from 26 patients were measured. Actual and ultrasonographic mean tonsillar volume (±SD) was 3.9 (±2.1) ml and 3.6 (±2.5) ml, respectively (P = 0.24). Ultrasonographic and actual measurements correlated well (r = 0.89). CONCLUSIONS This is the first study to show that ultrasound is a suitable objective method for determining tonsillar volume in paediatric patients. Preoperative ultrasound assessment of tonsillar anatomy and size may be an additional and suitable, objective method in the development of a risk stratification system in children with obstructive sleep apnoea undergoing tonsillar surgery.
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Affiliation(s)
- Panagiotis Asimakopoulos
- Department of Otolaryngology, Royal Aberdeen Children's Hospital, Aberdeen, Scotland, United Kingdom.
| | - David J L Pennell
- Department of Otolaryngology, Royal Aberdeen Children's Hospital, Aberdeen, Scotland, United Kingdom
| | - Constantinos Mamais
- Department of Otolaryngology, Royal Aberdeen Children's Hospital, Aberdeen, Scotland, United Kingdom
| | - Derek Veitch
- Department of Otolaryngology, Royal Aberdeen Children's Hospital, Aberdeen, Scotland, United Kingdom
| | - Samuel Stafrace
- Department of Radiology, Sidra Medical and Research Center, Doha, Qatar
| | - Thomas Engelhardt
- Department of Anaesthetics, Royal Aberdeen Children's Hospital, Aberdeen, Scotland, United Kingdom
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Abstract
Screening for obstructive sleep apnea (OSA) with in-laboratory polysomnography is recommended for children with sleep disordered breathing. Adenotonsillectomy is the first-line therapy for pediatric OSA, although intranasal steroids and montelukast can be considered for those with mild OSA and continuous positive airway pressure for those with moderate to severe OSA awaiting surgery, poor surgical candidates or persistent OSA. Bony or soft tissue upper airway surgery is reasonable for children failing medical management or those with persistent OSA following adenotonsillectomy. Weight loss and oral appliance therapy are also useful. A multi-modality approach to diagnosis and treatment is preferred.
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Affiliation(s)
- Zarmina Ehsan
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA
| | - Stacey L Ishman
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA; Division of Pediatric Otolaryngology - Head & Neck Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229, USA; University of Cincinnati School of Medicine, Department of Otolaryngology - Head & Neck Surgery, 231 Albert Sabin Way, MSB 6503, Cincinnati, Ohio 45267-0528, 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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Management of Young Patients with Temporomandibular Joint Ankylosis-a Surgical and Anesthetic Challenge. Indian J Surg 2016; 78:482-489. [PMID: 28100946 DOI: 10.1007/s12262-016-1551-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/05/2016] [Indexed: 12/19/2022] Open
Abstract
Temporomandibular joint ankylosis is a unique disease where fracture of the mandibular condyle or any other cause leading to ankylosis of the joint can lead to multiple problems if not detected and treated early. If affected in early years of life, it may cause facial dysmorphism, restricted mouth opening, and difficulty in eating, speech, and sleep. Early surgery and physiotherapy can restore the joint function to a great extent. Anesthetizing a pediatric patient with this disorder is a definite challenge which needs expertise in difficult airway management.
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Transoral robotic-assisted tongue base resection in pediatric obstructive sleep apnea syndrome: case presentation, clinical and technical consideration. Eur Arch Otorhinolaryngol 2016; 274:1161-1166. [PMID: 27568349 DOI: 10.1007/s00405-016-4269-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 08/13/2016] [Indexed: 12/19/2022]
Abstract
Pediatric obstructive sleep apnea syndrome (OSAS) is primarily caused by adenotonsillar hypertrophy. However, tongue base hypertrophy is increasingly being recognized as a cause, even after adenotonsillectomy. We report three cases of pediatric OSAS successfully treated by transoral robotic reduction of the tongue base. In all children, we were able to achieve improved retrolingual patency while avoiding significant procedure-related morbidity. In conclusion, tongue base reduction by transoral robotic surgery appears to be a feasible solution for the base of tongue obstruction due to lingual tonsil hypertrophy in pediatric patients.
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Whippey A, Kostandoff G, Ma HK, Cheng J, Thabane L, Paul J. Predictors of unanticipated admission following ambulatory surgery in the pediatric population: a retrospective case-control study. Paediatr Anaesth 2016; 26:831-7. [PMID: 27247224 DOI: 10.1111/pan.12937] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ambulatory surgery plays an important role in pediatric anesthesia. However, it is difficult to predict which patients will experience complications. Age >80, ASA class 3 or 4, duration of surgery >3 h, and BMI 30-35 are independent predictors of unanticipated admission in adults. In this study, we retrospectively evaluate risk factors for unanticipated admission, following ambulatory surgery in children. METHODS All ambulatory patients requiring unanticipated admission between 2005 and 2013 were compared to a random sample of patients not requiring admission in this case-control study. Demographic data, surgical information, medications, intraoperative events, and patient comorbidities were collected from both groups. The reason for admission was classified according to five subtypes. Multiple conditional logistic regression was used to assess factors associated with unanticipated admissions. RESULTS The incidence of unanticipated admission was 0.97% (213). Of these, 47% (98) was anesthesia related. Age <2 years (odds ratio [OR] 4.26 95% CI 1.19-15.25), ASA 3 class (OR 3.77 95% CI 1.46-9.71), duration of surgery >1 h (OR 6.54 95% CI 3.47-12.33), completion of surgery >3 pm (OR 2.17 95% CI 1.05-4.51), orthopedic (OR 2.52 95% CI 1.03-6.20), dental (OR 0.21 95% CI 0.06-0.81), ENT (OR 6.47 95% CI 2.99-14.03) surgery, intraoperative events (OR 4.45 95% CI 1.35-18.12), and OSA (OR 6.32 95% CI 1.54-25.94) were factors associated with unanticipated admission. CONCLUSION The incidence of unanticipated admission in children following ambulatory surgery is low. Age, ASA class, duration, and time of completion of surgery are predictors common to pediatrics and adults. Interestingly, intraoperative complications, OSA, and type of surgery (ENT, orthopedic, dental) are specific to pediatrics.
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Affiliation(s)
- Amanda Whippey
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | | | - Heung K Ma
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Ji Cheng
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - James Paul
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
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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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Vlastos I, Athanasopoulos I. Cutting-edge technologies for diagnosis and monitoring of snoring in children. World J Clin Pediatr 2016; 5:63-66. [PMID: 26862503 PMCID: PMC4737694 DOI: 10.5409/wjcp.v5.i1.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/17/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
Abstract
Snoring is a very common problem in children and may be an indication of obstructive sleep apnea (OSA). Appropriate diagnosis is of importance due to detrimental effects of OSA. Polysomnography is considered the gold standard for the diagnosis of OSA. However, it is impractical for several reasons and this is why other tests have been developed as alternatives to formal polysomnography (PSG) for the assessment of children with snoring. In this mini-review basic features of PSG as well as alternative tests are presented and future perspectives are provided in addition to current guideline for the diagnosis and monitoring of childhood snoring. The aim of this review is to highlight briefly currently developed technologies that seem promising for the evaluation of snoring.
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