Perioperative care following complex laryngotracheal reconstruction in infants and children

Postoperative management of pediatric patients undergoing single-stage laryngotracheal reconstruction in the United States: A survey of ASPO members

INTRODUCTION

The postoperative management of single-stage laryngotracheal reconstruction (ssLTR) plays a significant role in the surgery's outcomes. The relatively prolonged period in which the child remains intubated and sedated to allow graft healing may be complicated by pulmonary sequelae, airway obstruction, withdrawal symptoms, and eventually failed extubation. This study aims to assess post-ssLTR practices among pediatric otolaryngologists.

METHOD

An electronic cross-sectional survey was distributed to the American Society of Pediatric Otolaryngology (ASPO) members to elucidate current protocols in post-ssLTR practice in the United States.

RESULTS

Eighty-six responses were recorded. A majority (60 %; n = 50) reported performing fewer than five ssLTRs per year. The mean time to bronchoscopy following ssLTR was postoperative day 8±3 for ssLTR with a posterior graft and postoperative day 7±3 without a posterior graft. Most practitioners reported avoiding paralytics (61 %, n = 44) unless the desired level of sedation could not be achieved. Most providers utilized pre-pyloric feeding via a nasogastric or gastrostomy tube (n = 50, 72 %). A total of 70 % (n = 49) of respondents use a single medication for acid suppression, whereas 21 % (n = 15) reported dual-acid suppression whether the patient was diagnosed with gastroesophageal reflux prior to surgery or not, regardless of feeding route. Nebulized agents were routinely used, with normal saline (43 %; n = 36) being the most reported agent.

CONCLUSION

The postoperative management after ssLTR varies greatly among pediatric otolaryngologists due to a lack of evidence-based data to support one protocol over the other. Multi-institutional studies should be considered to evaluate current protocols and improve postoperative care.

Immediate extubation after single-stage laryngotracheal reconstruction for subglottic stenosis in children

PURPOSE

To evaluate the feasibility and clarify the appropriate indications for extubation immediately after single-stage laryngotracheal reconstruction (SS-LTR) in pediatric subglottic stenosis (SGS).

METHODS

A retrospective study was performed from July 2017 to July 2022. All patients underwent SS-LTR with anterior costal cartilage graft. Information such as demographics, comorbidities, history of intubation or tracheostomy, Classification and grading of airway stenosis, the operation-specific decannulation rate and overall decannulation rate were analyzed.

RESULTS

Twenty-two patients with simple SGS were identified. The median age at SS-LTR was 19 months (IQR = 18.5 months). Fourteen patients (63.6%) were intubated prior to the presentation of symptoms. Fourteen patients (63.6%) required preoperative tracheostomy to maintain a secure airway. Eight patients (36.4%) had congenital SGS, 10 patients (45.5%) had acquired SGS, and 4 patients (18.2%) had mixed SGS. Three patients had Grade II stenosis. Nineteen patients had Grade III stenosis. Comorbidities were found in 10 patients (45.5%). Major comorbidities were pneumonia. Congenital airway anomalies were found in 6 patients (27.3%). After anesthesia, all 22 patients were successfully extubated and returned to the general ward. Twenty patients had a satisfactory airway after SS-LTR. Two patients required reintubation or tracheostomy after operation. Operation-specific decannulation rate was 90.9%. The overall decannulation rate is 100%.

CONCLUSION

SS-LTR with anterior costal cartilage graft is an effective method to treat simple SGS ranging from Grades I to III in children. Extubation immediately after surgery is safe and feasible.

Reevaluating a Standardized Sedation Weaning Protocol for Pediatric Laryngotracheal Reconstruction for Continuous Quality Improvement

Importance

Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation.

Objective

Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR).

Design, Setting, and Participants

A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients.

Main Outcomes and Measures

The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission.

Results

The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS.

Conclusions and Relevance

Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.

Outcomes Using a Postoperative Protocol in Pediatric Single-Stage Laryngotracheal Reconstruction

OBJECTIVES

The aim of this study was to evaluate single-stage laryngotracheal reconstruction (ssLTR) outcomes before and after the implementation of a postoperative care protocol in pediatric patients.

METHODS

A case-control study with chart review was conducted at 2 tertiary academic centers from 2010 to 2016. Pediatric patients who underwent ssLTR with a postoperative care protocol were compared with those who did not receive care under this protocol. Data regarding perioperative management were collected and compared using χ² and Wilcoxon rank tests. Planned extubation, length of intubation in the intensive care unit, and complications were examined.

RESULTS

Nineteen patients completed ssLTR after the protocol was initiated, and 26 prior patients were used as control subjects. Planned extubation failed in 9 patients (35%) in the control group compared with 1 patient (5%) in the protocol group (P < .05). Using a structured protocol demonstrated a decrease in delayed extubation and intensive care unit stay (P < .05). Despite more postprotocol patients' requiring posterior graft placement, preprotocol patients were less likely to be extubated within 7 days (P < .05).

CONCLUSIONS

The authors propose an intensive care unit protocol that uses a combination of pharmacologic agents to optimally reduce the risk for adverse events that delay time to extubation and thus decannulation. Timely extubation was more likely with the use of this postoperative care protocol using a multidisciplinary approach involving otolaryngologists, pharmacists, intensivists, and anesthesiologists.

Sedation-related outcomes in postoperative management of pediatric laryngotracheal reconstruction

OBJECTIVE

Examine outcomes of varied postoperative sedation management in pediatric patients recovering from single stage laryngotracheal reconstruction.

DESIGN

Retrospective review of 34 patients treated with single stage laryngotracheal reconstruction from 2001 through 2011.

SETTING

Tertiary children's hospital.

METHODS

Patients were divided into 2 groups: those managed postoperatively with sedation, with or without paralysis (group 1), and those managed awake with narcotic pain medication as needed for primary management (group 2). Outcomes were measured as a function of sedation management. Outcomes investigated focused on those related to the success of the airway reconstruction, and those related to sedation management.

RESULTS

Out of 68 cases of laryngotracheal reconstruction reviewed from 2001 to 2011, 34 were single stage reconstructions. Nineteen patients were sedated postoperatively (group 1) and fifteen patients were left awake (group 2). There were no significant differences between groups in airway-related outcomes, including risk of accidental decannulation, revision rates, and need for secondary airway procedures such as balloon dilation. Sedation-related outcomes, specifically focusing on differences in medical management, showed significant increases in rates of withdrawal (p<0.0001), nursing concerns of withdrawal (p<0.0001) and sedation level (p<0.0001), pulmonary complications (OR 7.7, p=0.008), and prolonged hospital stay due to withdrawal (p=0.0005) in patients managed with sedation with or without paralysis. Multivariable regression analysis revealed that duration of sedation was the primary risk factor for increased postoperative morbidity, while younger age, lower weight, and use of a posterior graft were also significant variables assessed.

CONCLUSION

Avoiding sedation as the standard for postoperative management of single stage laryngotracheal reconstruction airway patients leads to an overall decreased risk of morbidity without increasing risk of airway-specific morbidity. This is specifically as related to withdrawal, pulmonary complications, concerns about sedation level and prolonged hospital course, all of which increase significantly with increased level and duration of sedation.

Dexmedetomidine as a Primary Sedative Agent after Single-Stage Airway Reconstruction

Objective

To examine the outcomes of children receiving dexmedetomidine after single-stage airway reconstruction.

Study Design

Historical cohort study.

Setting

Tertiary care children’s hospital.

Subjects and Methods

Of 61 eligible patients, 50 children undergoing single-stage airway reconstruction were included in the study. Thirty children received dexmedetomidine (Dex) as a primary sedative agent, and 20 received a more traditional sedation protocol (no Dex). Primary outcomes included complications, intubation lengths, and lengths of pediatric intensive care unit (PICU)/hospital admission. Secondary analysis incorporating polypharmacy and age was performed using multivariate linear regression models.

Results

Median age was 18.0 months. Age, sex, and weight were similar between the groups. Intubation length was equal in the 2 groups, and there were no statistical differences between lengths of PICU or hospital stay after extubation. Similarly, overall and individual complications were all similar, and there was no difference between the 2 groups in the amount of polypharmacy administered. On multivariate analysis, polypharmacy and younger age were independently correlated with an increase in overall complications, and polypharmacy alone was correlated with an increased length of stay after extubation.

Conclusion

The use of dexmedetomidine as a primary sedation agent after single-stage airway surgery does not appear to improve outcomes or decrease the need for additional pharmacologic agents. Polypharmacy was associated with an increase in overall complications and an increased length of stay after extubation. Although success can be expected in greater than 90% of these surgical patients, the optimal postoperative sedation management remains challenging.