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CO2-Lasertonsillotomy Under Local Anesthesia in Adults
Published on: November 6, 2019
Routine post-operative intensive care is not necessary for children with obstructive sleep apnea at high risk after
Marc Theilhaber1, Sarah Arachchi1, David S Armstrong2
1Melbourne Children's Sleep Centre, Monash Children's Hospital, Monash Medical Centre, Melbourne, Australia.
Insights
Routine intensive care unit (ICU) admission after adenotonsillectomy (AT) for obstructive sleep apnea (OSA) may be unnecessary for many high-risk children. Severe post-operative respiratory adverse events (AE) are infrequent, suggesting PACU monitoring may suffice for most patients.
Area of Science:
- Pediatric Anesthesiology
- Sleep Medicine
- Critical Care Medicine
Background:
- Post-operative respiratory adverse events (AE) are common in children undergoing adenotonsillectomy (AT) for obstructive sleep apnea (OSA).
- Many institutions routinely admit at-risk children to the intensive care unit (ICU) post-operatively.
- The appropriateness of routine ICU admission requires evaluation.
Purpose of the Study:
- To determine the frequency and severity of post-operative AE in children admitted to the ICU after AT for OSA.
- To assess the necessity of routine ICU care for these patients.
Main Methods:
- Retrospective chart review of children admitted to the pediatric ICU after AT for OSA (January 2007-December 2009).
- AE were classified as mild (e.g., supplemental oxygen) or severe (e.g., re-intubation, unplanned ICU admission).
Main Results:
- 72 children were reviewed; 36% experienced AE, with 8.3% having severe AE.
- Age, sex, comorbidities, or OSA severity did not predict severe AE.
- A negative predictive value of 98.3% was found for severe AE if no AE occurred in the post-anesthetic care unit (PACU).
Conclusions:
- High rates of AE occur after AT in high-risk children, but severe events requiring ICU care are infrequent (8%).
- Severe AE were unlikely if no AE occurred in the PACU.
- Routine ICU admission may be avoidable for high-risk children if prolonged PACU monitoring is available; ICU admission should be reserved for those with early AE.
Objectives:
Post-operative respiratory adverse events (AE) are frequent in children having adenotonsillectomy (AT) for obstructive sleep apnea (OSA). Many hospitals have a policy of routine admission to the intensive care unit (ICU) after surgery for children at highest risk. We aimed to determine the frequency and severity of post-operative AE in children admitted to ICU, to assess the appropriateness of this care plan.
Methods:
A retrospective chart review was carried out all children admitted to the pediatric intensive care unit after AT for OSA from January 2007 to December 2009. AE were classified as mild, including requirement for supplemental O2 or repositioning to improve airway or severe, including bag and mask ventilation, CPAP, re-intubation, placement of oropharyngeal airway or unplanned ICU admission for airway compromise.
Results:
72 children were identified (21 female, median age 2.8 years). There were 29 AE in 26 patients (36%), including 23 (31.9%) who suffered a mild AE and 6 (8.3%) who had a severe AE. Age, sex, the presence of co-morbidity or the presence of severe OSA did not predict severe AE in this group. Median time to first AE was 165min. Four of the six severe AE occurred in the post-anesthetic care unit (PACU). There were 60 children who did not have an AE in PACU, of whom 59 did not have a severe AE in the post-operative period, giving a negative predictive value for no worse than a mild AE following an uncomplicated course in PACU of 98.3%.
Conclusions:
Our data confirm high rates of AE after AT for high risk patients, however, only 8% suffered a severe AE truly necessitating care in ICU. This outcome was very unlikely if an AE did not occur in PACU. We therefore conclude that routine post-operative ICU care for high risk children may be avoided if prolonged monitoring in the PACU is possible, with admission to ICU reserved for high-risk children with an early AE.
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