Anesthesiological considerations for children with obstructive sleep apnea

Abstract

Perioperative deaths in children with OSA occur at a low frequency. Hypoxia-induced opioid sensitivity combined with an approximate 1-2% incidence of rapid conversion of codeine to morphine suggest the need for new approaches for providing preoperative assessment of risk, extended postoperative observation and the need for alternative opioids to codeine. Additionally, new less painful surgical approaches may help to reduce postoperative opioid requirements and therefore perhaps less risk for opiate-induced apnea in this vulnerable population.

Otolaryngology practice patterns in pediatric tonsillectomy: The impact of the codeine boxed warning

“…Some practitioners do not give any narcotic prescriptions postoperatively, some give them only for rescue, and some prescribe them routinely. Even the choice of appropriate narcotic medication is not clear; hydrocodone was the most frequently given noncodeine narcotic prescription in the study cohort (accounting for 91% of such prescriptions), but it also is metabolized to morphine by the CYP2D6 system, theoretically posing an increased risk in patients with susceptible genetic polymorphisms . This risk is related to the fact that its active metabolite is hydromorphone, which is quite potent and centrally active, unlike oxycodone which does not have a centrally active metabolite.…”

“…This would suggest that patient and parent experience is no worse after the boxed warning than before, but whether care has been improved remains to be demonstrated. There has been increasing emphasis on the role of preoperative and perioperative pain prevention in the anesthesia literature; with the publication of effective preventative regimens there is more widespread use and acceptance . The role of intraoperative corticosteroid in preventing postoperative nausea and vomiting and limiting postsurgical inflammation is well accepted, and almost all pediatric patients receive intravenous antiemetic during surgery in the form of a 5HT3 receptor antagonist such as ondansetron .…”

Double-Blind Randomized Placebo-Controlled Trial of Single-Dose Intravenous Acetaminophen for Pain Associated With Adenotonsillectomy in Pediatric Patients With Sleep-Disordered Breathing

“…Despite the positive postoperative outcome for our study subjects, continued focus and research is needed toward optimizing and even differentiating postoperative pain management and education in pediatric patients with SDB versus OSA following adenotonsillectomy given the significant rates of readmission for pain-related issues and the alarming cases of posttonsillectomy mortality outside the hospital setting due to possible opiate overuse, especially in children with OSA. 25,26 Limitations of our study include the fact that it involves data from a single and not a multicenter enrollment process. In addition, patients were not enrolled if their BMI was > 95% or if there was a diagnosis of severe OSA necessitating planned intensive care unit admission.…”

Obstructive Sleep Apnea: Preoperative Screening and Postoperative Care

“…The most common cause of OSA in children is adenotonsillar hypertrophy, and adenotonsillectomy is the primary treatment for this condition, curing OSA in 70% of children. 12,13 OSA is also associated with obesity and chronic upper airway inflammatory disorders, including sinusitis, allergic rhinitis, and asthma. 14 Children are less likely to report daytime drowsiness.…”