Postoperative Monitoring Following Adenotonsillectomy for Severe Obstructive Sleep Apnea

Rhodes, Cecil; Eid, Anas; Muller, Grant; Kull, Amanda; Head, Tim; Mamidala, Madhu; Gillespie, Boyd M.; Sheyn, Anthony

doi:10.1177/0003489418794700

Cited by 9 publications

(20 citation statements)

References 26 publications

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“…One novelty of our study is that it reviews a large cohort of 179 high‐risk children who were admitted to the PICU post‐TA; this high‐risk cohort is unique in that it includes a large percentage of children with co‐morbid states. Unlike other studies we report that an uneventful 2‐hour PACU course is insufficient to exclude probability of later respiratory AEs. Similar to Rhodes we found the presence of severe OSA was associated with a trend toward higher risk of PICU events even in children with an uneventful PACU course …”

Section: Discussioncontrasting

confidence: 99%

“…Unlike other studies we report that an uneventful 2‐hour PACU course is insufficient to exclude probability of later respiratory AEs. Similar to Rhodes we found the presence of severe OSA was associated with a trend toward higher risk of PICU events even in children with an uneventful PACU course …”

Section: Discussioncontrasting

confidence: 99%

“…Rohdes, more recently, looked at post‐TA children with severe OSA and based PICU admission on occurrence of >2 episodes of desaturation to <70% during a 3‐hour PACU course. They found that age <2 years and AHI >50 on polysomnography were predictive of PICU admission . Similarly, we also found that the presence of severe OSA was associated with a trend toward higher risk of PICU events even in children with an uneventful PACU course (OR: 2.2, P ‐value .06).…”

Section: Discussionsupporting

confidence: 77%

“…APICU bed should be available but admission should be individualized . Precise guidelines on planned PICU admission are still evolving …”

Section: Introductionmentioning

confidence: 99%

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Respiratory complications after adenotonsillectomy in high‐risk children with obstructive sleep apnea: A retrospective cohort study

Ekstein

Zac

Schvartz

et al. 2019

Acta Anaesthesiol Scand

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Over the past 30 years, adenotonsillectomy (TA) is increasingly performed in children. 1 The indication for surgery has evolved over time and the surgical indication for over 75% of cases is pharyngeal obstruction in the presence of obstructive sleep apnea (OSA) 2,3 rather than for recurrent infection. The mainstay of OSA treatment is TA. 1,4 A prospective randomized study of 464 children aged 5-9 demonstrated efficacy in reducing symptoms, improving child behavior, quality of life, and improved sleep study results compared with conservative treatment with supportive and watchful waiting. 5 Some children with OSA are at increased risk of post-operative respiratory complications either because of the severity of their OSA, 6 age less than 2 years, 7,8 or co-morbid disease states. 4,6-9 While there are specific guidelines regarding post-operative care after TA in children with OSA from the American Academy of Otolaryngology-Head Background: Obstructive sleep apnea (OSA) occurs in 1%-4% of children; adenotonsillectomy is an effective treatment. Mortality/severe brain injury occurs among 0.6/10 000 adenotonsillectomies; in children, 60% are secondary to airway/respiratory events. Earlier studies identified that children aged <2 years, extremes of weight, with co-morbidities of craniofacial, neuromuscular, cardiac/respiratory disease, or severe OSA are at high risk for adverse post-operative respiratory events (AE). We aimed to: Firstly, investigate which risk factors were associated with AEs either in the post-anesthesia care unit (PACU), pediatric intensive care unit (PICU), or both in this population. Secondly, we investigated factors associated with post-operative PICU AE despite no event in the PACU in order to predict need of post-operative PICU after their PACU stay. Methods: Retrospective study of children admitted to the PICU after adenotonsillectomy between 08/2006-09/2015. Demographics, risk factors, and occurrence of AE (oxygen saturation <92, stridor, bronchospasm, pneumonia, pulmonary edema, re-intubation) were recorded. Results: During the studied time period 4029 tonsil/adenoid procedures were performed in 3997 children. 179, admitted to the PICU post-operatively, met criteria for analysis. PICU AEs occurred in 59%: 44%-83% in any particular risk category. PACU AEs occurred in 42%. Of those with PACU events: 92% suffered AEs in the PICU; however, 35% of those without a PACU AE still suffered a PICU AE. Conclusions: Among high-risk children undergoing TA, absence of adverse events in PACU during a 2-hour observation period does not predict absence of subsequent AEs in the PICU.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussioncontrasting

confidence: 99%

Section: Discussionsupporting

confidence: 77%

“…APICU bed should be available but admission should be individualized . Precise guidelines on planned PICU admission are still evolving …”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Respiratory complications after adenotonsillectomy in high‐risk children with obstructive sleep apnea: A retrospective cohort study

Ekstein

Zac

Schvartz

et al. 2019

Acta Anaesthesiol Scand

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“…Other possible pre‐operative risk factors have been described. Among these are several items derived from pre‐operative PSG or pulse oximetry, such as the apnoea‐hypopnoea‐Index (AHI) , capillary oxygen saturation (S p O 2 ) , respiratory disturbance index (RHI) or a significant central component in PSG .…”

Section: Discussionmentioning

confidence: 99%

Risk factors for children requiring adenotonsillectomy and their impact on postoperative complications: a retrospective analysis of 2000 patients

et al. 2019

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Summary Adenotonsillectomies are commonly performed procedures and sleep‐disordered breathing is becoming increasingly important as an indication for surgery. Because of the higher risks in patients with obstructive sleep apnoea, the required level of postoperative care for these patients is currently under discussion, and better identification of patients at risk may reduce unnecessary postoperative monitoring. To evaluate the influence of obstructive sleep apnoea, and other risk factors, on peri‐operative complications in children requiring adenotonsillectomy, we performed a retrospective case‐control study that included 1995 patients treated between January 2009 and June 2017. In our analysis, young age (OR 3.8, 95%CI 2.1–7.1), low body weight (OR 2.6, 95%CI 1.5–4.4), obstructive sleep apnoea (OR 2.4, 95%CI 1.5–3.8), pre‐existing craniofacial or syndromal disorders (OR 2.3, 95%CI 1.4–3.8) and adenotonsillectomy, compared with adenoidectomy alone, (OR 7.9, 95%CI 4.7–13.1) were identified as risk factors for complications during or after surgery, p < 0.001. All 13 patients suffering from complications more than 3 h postoperatively had obstructive sleep apnoea plus at least one more of these risk factors. Patients at risk of postoperative complications can therefore be identified by several criteria pre‐operatively, and should be monitored postoperatively using pulse oximetry overnight. For all other patients, postoperative observation on a surgical ward without extra monitoring is sufficient. Admission to paediatric intensive care should be reserved for patients suffering serious intra‐operative complications.

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Pediatric Postoperative Outcomes for Severe and Very Severe Obstructive Sleep Apnea Syndrome

Hurly,

Clements,

Ryan

et al. 2024

The Laryngoscope

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ObjectiveTo determine if increasing obstructive sleep apnea syndrome (OSAS) severity, as determined by preoperative polysomnography data, is an independent risk for respiratory complications and level of follow‐up care after adenotonsillectomy or tonsillectomy.MethodsA retrospective analysis of patients ≤21 years of age with severe OSAS (obstructive apnea–hypopnea index [OAHI] >10) undergoing adenotonsillectomy or tonsillectomy. Patients were categorized based on preoperative polysomnography data (PSG). Outcome measures including respiratory complications were collected via chart review. Logistic regression was used in the analysis of all parameters, and Wilcoxon Rank Sum tests were used for analysis of both OAHI and oxygen saturation nadir as continuous variables. All surgeries were performed at Johns Hopkins Hospital, a tertiary care center.ResultsWe identified 358 patients with severe OSAS who had adenotonsillectomy or tonsillectomy. OAHI >40 and oxygen saturation nadir <80% were significantly associated with postoperative respiratory complications. Increasing OAHI and O2 saturation <80% was each associated with unplanned continuous positive airway pressure (CPAP) initiations postoperatively. There was no association between hypercarbia and presence of any complications.ConclusionPatients with very severe OSAS (preoperative OAHI ≥40) as determined by preoperative PSG may be at higher risk of developing respiratory complications postoperatively. However, there does not appear to be a linear association with increasing severity of OAHI on regression analysis. Further research is needed to understand factors associated with complications in severe and very severe OAHI.Level of Evidence4 Laryngoscope, 2024

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Postoperative Monitoring Following Adenotonsillectomy for Severe Obstructive Sleep Apnea

Abstract: Based on the data presented here and academy recommendations, not all patients with severe OSA require ICU monitoring.

Cited by 9 publications

References 26 publications

Respiratory complications after adenotonsillectomy in high‐risk children with obstructive sleep apnea: A retrospective cohort study

Respiratory complications after adenotonsillectomy in high‐risk children with obstructive sleep apnea: A retrospective cohort study

Risk factors for children requiring adenotonsillectomy and their impact on postoperative complications: a retrospective analysis of 2000 patients

Pediatric Postoperative Outcomes for Severe and Very Severe Obstructive Sleep Apnea Syndrome

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