Postoperative admission to paediatric intensive care after tonsillectomy

Abstract

Objectives: To review interventions required by children admitted for intensive care management following tonsillectomy or adenotonsillectomy either as elective or unplanned admission in a tertiary children’s hospital. Methods: A retrospective chart review over a 10-year period between April 2007 and March 2017 was performed. Charts were interrogated for treatments that were administered in the paediatric intensive care unit. Respiratory support therapies such as supplemental oxygen administration, high-flow nasal oxygen, positive pressure ventilation, continuous positive airway pressure, airway interventions and tracheal intubation were reviewed. Results: There were 103 children admitted to the paediatric intensive care unit following tonsillectomy or adenotonsillectomy. The average age was 6.2 years (range 7 months–17 years). The main indications for the procedure were sleep disordered breathing or obstructive sleep apnoea syndrome. In all, 53 children had syndromes with medical comorbidities, 31 were current continuous positive airway pressure users and 5 had a tracheostomy in situ. Forty children admitted to paediatric intensive care unit did not require any high-level care. Ten children who had an unplanned admission had their respiratory interventions started in the theatre or in the post-anaesthetic care unit, before paediatric intensive care unit admission, and did not require escalation of care. Conclusion: Children may not require admission for intensive care after tonsillectomy if they have had an incident-free period in the post-anaesthetic care unit. Some of those who required high-flow nasal oxygen could have been managed on the ward provided with adequate training and monitoring facilities. The level of care they require in post-anaesthetic care unit reflected the level of care for the immediate postoperative period in the paediatric intensive care unit.

Preoperative Predictors of Severe Respiratory Events After Tonsillectomy: Consideration for Pediatric Intensive Care Admission

“…Past studies of children with pretonsillectomy PSG have demonstrated that rates of severe postoperative respiratory complications range widely, from <1% to 60%. The wide range of estimates is due to differences in the definition of respiratory events and the samples studied 3,5,7,10,11,14,15,25,27,38‐42 . Studies with estimates at the lower end of the range used more stringent definitions of SRE within a more inclusive sample of high and low‐risk patients, while those at the upper end reported on both major and minor SRE within higher‐risk patients (eg, only those with severe OSA or only those admitted to the PICU postoperatively).…”

“…1,2 The reported frequency of post-AT respiratory events ranges widely, from <1% to nearly 60%, depending on the definition of events and population studied. [3][4][5][6][7][8][9][10][11][12][13][14] Some children can safely undergo outpatient AT, whereas others require inpatient observation to monitor for postoperative respiratory events. Some children are admitted to the pediatric intensive care unit (PICU) after AT due to perceived increased risk for severe respiratory events (SRE).…”

“…Although AT is one of the most common pediatric procedures performed in the United States, it can result in severe and life‐threatening respiratory events 1,2 . The reported frequency of post‐AT respiratory events ranges widely, from <1% to nearly 60%, depending on the definition of events and population studied 3‐14 . Some children can safely undergo outpatient AT, whereas others require inpatient observation to monitor for postoperative respiratory events.…”

Cost‐minimisation analysis of polysomnography and pulse oximetry in a risk stratification protocol for paediatric adenotonsillectomy

“…As PICU LOS hours was not recorded in the original dataset, a conservative estimate of 24 h was used based upon existing research by Levi et al who reports 72.8% of children are discharged to the ward within 24 h following PICU admission post-AT. 37 Applied to a vulnerable paediatric population, increased oximetry costs must be balanced against economic and non-economic costs of the alternative. As Australia reports high rates of paediatric tonsillectomy in regional areas, 38 cost of regional inter-hospital transfer may be higher than in metropolitan settings.…”

“…As PICU LOS hours was not recorded in the original dataset, a conservative estimate of 24 h was used based upon existing research by Levi et al . who reports 72.8% of children are discharged to the ward within 24 h following PICU admission post‐AT 37 …”