A pilot study to identify pre- and peri-operative risk factors for airway complications following adenotonsillectomy for treatment of severe pediatric OSA

doi:10.1016/j.ijporl.2011.07.034

International Journal of Pediatric Otorhinolaryngology

Volume 75, Issue 11, November 2011, Pages 1385-1390

https://doi.org/10.1016/j.ijporl.2011.07.034 Get rights and content

Abstract

Objective

A pilot study to identify risk factors predicting post-operative complications in children with severe OSA undergoing adenotonsillectomy.

Methods

Retrospective review in a tertiary care academic institution. Two-stage least squares regression analysis and instrumental variable analysis to allow for modeling of pre- and peri-operative risk factors as having significance in predicting post-operative morbidity.

Results

Eighty-three children (mean age 4.88 ± 3.09 years) with apnea-hypopnea index (AHI) ≥10 who were observed overnight following adenotonsillectomy were evaluated for rates of major (increased level of care, CPAP/BiPAP use, pulmonary edema and reintubation) and minor (oxygen saturation <90%) airway complications as well as total observation costs. Major and minor complications occurred in 4.8% and 19.3% of children, respectively. Age <2 years (p < 0.01), AHI >24 (p < 0.05), intra-operative laryngospasm requiring treatment (p < 0.05), oxygen saturations <90% on room air in PACU (p < 0.05) and PACU stay >100 min (p < 0.01) independently predicted post-operative complications. Children with any one of these factors experienced a 38% complication rate versus 4% in all others.

Conclusions

This pilot study identified pre- and peri-operative risk factors that collectively can be investigated as predictors of post-operative airway complications in a prospective study. By identifying preliminary results comparing the complication rates between those children with and without these risk factors, we will be able to calculate the sample size for a future prospective validation study. Such a study is necessary to understand the safety and potential significant cost savings of observing children without risk factors on the pediatric floor and not in an ICU setting. A best practice algorithm can be created for children with severe OSA only after completing this prospective study.

Section snippets

Methods

Institutional review board approval was obtained from the Massachusetts Eye and Ear and Infirmary (MEEI) and from Massachusetts General Hospital (MGH). The MEEI Pediatric Sleep Laboratory database was queried for children up to age 18 with severe OSA (total AHI ≥10) diagnosed by PSG from March 2007 to July 2010. This list was cross-referenced with a database of all adenotonsillectomies performed by two pediatric otolaryngologists at MEEI (CJH, DGK) during the same time period to identify those

Results

Eighty-three children were diagnosed with severe OSA by overnight PSG, treated surgically with T&A and were observed overnight in the pediatric floor, step-down unit or PICU. This cohort had a mean age of 4.88 ± 3.09 years and a preponderance of male patients (M:F 1.79:1). Polysomnography revealed a mean total AHI of 23.62 ± 13.76 (range: 10.1–88.8) and mean total obstructive apneas with all hypopneic episodes of 21.77 ± 13.54. Sixteen children (19.28%) were obese, while 10 (12.05%) were failing to

Discussion

The American Academy of Otolaryngology – Head and Neck Surgery recommends that children with significant OSA be hospitalized after surgery [1], however there remains a lack of guidelines for whether these children should be admitted to the floor or a monitored setting, such as a PICU or a step-down unit. This study aimed to identify which pre- and peri-operative factors should be investigated further with a prospective study in order to determine if they are strong predictors of airway

Conflict of interest

The authors have no financial, personal, academic or intellectual conflicts of interest to disclose.

Acknowledgment

No funding was provided for this project.

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Describe the impact of the implementation of an evidence-based pediatric preoperative risk assessment (PPRA) checklist on the frequency of postanesthesia care unit (PACU) nursing assessments and interventions in children at risk for respiratory complications during emergence from anesthesia.
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Demographic variables, risk factors, frequency of nursing assessments/interventions were summarized in pre-/postinterventions. Significant differences (P < .001) were noted between pre-/postintervention groups with increased frequency of postnursing assessments/interventions that correlated with increased risk factors and weighted risk factors.
By identifying total PPRFs, PACU nurses used their plan of care to frequently assess and pre-emptively intervene with children who had increased risk factors to prevent or mitigate respiratory complications on emergence from anesthesia.
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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.
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.
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.
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.
Admission practices following pediatric tonsillectomy: A survey of ASPO members
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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.
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.
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).
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.
Development of an Evidence-Based Pediatric Preoperative Risk Assessment Checklist
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Citation Excerpt :
This collaborative policy statement with the American Academy of Pediatrics (AAP) and the American Society of Anesthesiologists (ASA) was a culmination of the past 50 years of published studies that focused on the following: credentialing by administrators for appropriate competent providers; identifying children with pediatric risk factors; ensuring age and size appropriate equipment; recommending medical and nursing pediatric competencies for surgeons, anesthesiologists, operating room nurses, and PACU nurses; and foremost, providing a safe quality perioperative care environment for patients and families.2,6 Multiple anesthesia and pediatric research studies have identified independent PPRF that are associated with PACU respiratory complications, or PRAE, and include ASA-Physical Status (ASA-PS) II, III, age, gender, airway comorbidities, syndromes, anomalies, pulmonary comorbidities, African American ethnicity, obesity, neurologic comorbidities, cardiac comorbidities and surgeries that are in close proximity to the airway.2-6,8-26 The ASA-PS clinical scoring system provides a measure to evaluate the patient's preoperative physical condition and/or functional state.
To describe how a pediatric preoperative risk assessment (PPRA) checklist was developed to inform perianesthesia nurses of potential postanesthesia care unit (PACU) respiratory complications.
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A systematic search was conducted using PubMed, CINAHL and Cochrane Library databases for this project. In addition, an integrative review process was conducted to develop an assessment checklist of evidence-based pediatric preoperative risk factor criteria associated with PACU respiratory complications. Evidence-based review focused on summarizing and appraising current research for quality levels for each of the individual pediatric preoperative risk factor that comprised the assessment checklist.
Eleven risk categories were established: Age, American Society of Anesthesiologists Physical Status, gender, general anesthesia, airway comorbidities, syndromes/congenital anomalies, pulmonary comorbidities, African American ethnicity, obesity, neurologic comorbidities, and cardiac comorbidities. Multidisciplinary experts came to consensus on content and face validity as well as reliability of the PPRA checklist.
The PPRA checklist presents a rapid way to communicate through handoff the preoperative “big picture” to interpret children's acuity and comprehensive risk for significant pediatric respiratory adverse events in the PACU.
PICU admission and complications following adenotonsillectomies in pediatric patients: A retrospective cohort study
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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.
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.
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).
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.
Does length of time between cases affect resident operative time for tonsillectomy and adenoidectomy?
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To evaluate the effect of prolonged time intervals between tonsillectomy and adenoidectomy (TA) on resident operative time and complications.
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Tertiary academic hospital.
This retrospective study covers a five-year period from 2015 to 2020. Time intervals between isolated pediatric TA cases performed by eight otolaryngology residents were reviewed to assess effect on operative time (defined as prolonged if ≥ 30 min and non-prolonged if < 30 min). Intervals including a procedure involving either a tonsillectomy or adenoidectomy that was a non-isolated TA were excluded.
A total of 309 isolated TAs were identified with 67.3% of procedures performed under 30 min. The mean surgical time interval between procedures was 5.83 ± 10.02 days (range 0.02–69.82). Most TAs were performed on patients aged 7 years or younger. Surgical time interval between TA was not a significant factor in determining prolonged operative time on univariable logistic regression, OR 1.01 (CI: 0.98 to 1.03) (p = 0.63). Patient age at surgery, adenoid grade, tonsil size and total number of TAs performed to date were significant factors in determining prolonged operative time in both univariable and multivariable logistic regression models. Prolonged operative time did not have a significant effect on readmission, reoperation, or post-operative bleeding.
Extended time interval (up to 3 months) between routine TA does not affect operative time. Expansion of our methodology to more complex cases would be beneficial in designing resident training curriculum.

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^☆: This paper was presented at the podium of the American Society of Pediatric Otolaryngology Annual Meeting in conjunction with the Combined Otolaryngology Spring Meetings in Chicago, IL, on April 29, 2011.

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A pilot study to identify pre- and peri-operative risk factors for airway complications following adenotonsillectomy for treatment of severe pediatric OSA☆

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conflict of interest

Acknowledgment

Sleep Med.

Chest

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Otolaryngol. Head Neck Surg.

Otolaryngol. Head Neck Surg.

Otolaryngol. Head Neck Surg.

Otolaryngol. Head Neck Surg.

Int. J. Pediatr. Otorhinolaryngol.

Int. J. Pediatr. Otorhinolaryngol.

Otolaryngol. Head Neck Surg.

Clinical practice guideline: tonsillectomy in children

Otolaryngol. Head Neck Surg.

Cardiac, lung, and brain thrombosis in a child with obstructive sleep apnea

Pediatr. Pulmonol.

Activity-adjusted 24-hour ambulatory blood pressure and cardiac remodeling in children with sleep disordered breathing

Hypertension