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Anesthesiological considerations for children with obstructive sleep apnea
1Department of Anesthesia, Critical Care and Pain Management, Division of Pediatric Anesthesia, Harvard Medical School, The MassGeneral Hospital for Children, Massachusetts General Hospital, Boston, Massachusetts, USA.
Insights
Children with obstructive sleep apnea (OSA) face risks after surgery, including apnea and opioid sensitivity. New strategies for risk assessment and pain management are needed to prevent perioperative deaths.
Area of Science:
- Pediatric Anesthesiology
- Otolaryngology
- Pharmacogenomics
Background:
- Obstructive sleep apnea (OSA) in children presents unique perioperative challenges.
- Post-tonsillectomy deaths linked to apnea have been reported, sometimes occurring after routine monitoring cessation.
- Genetic variations affecting codeine metabolism and opioid receptor sensitivity due to hypoxemia are critical factors.
Purpose of the Study:
- To review current evidence on outcomes for children with obstructive sleep apnea (OSA).
- To highlight risks associated with anesthesia and surgery in pediatric OSA patients.
- To inform clinical practice regarding perioperative care for this population.
Main Methods:
- Review of internet surveys from pediatric otolaryngologists and anesthesiologists.
- Analysis of reported perioperative deaths in children with OSA.
- Examination of evidence regarding genetic factors (cytochrome P450) and hypoxemia effects on opioid response.
Main Results:
- A significant number of deaths within 24 hours of tonsillectomy were attributed to post-surgical/anesthesia apnea.
- Deaths occurred even after the removal of standard monitoring equipment in the post-anesthesia care unit.
- Children with specific genetic profiles (duplicated cytochromes) are at risk for codeine overdose, and hypoxemia may increase opioid sensitivity.
Conclusions:
- Perioperative deaths in children with OSA, while infrequent, necessitate improved management strategies.
- The combination of hypoxia-induced opioid sensitivity and rapid codeine metabolism (1-2% incidence) requires alternative approaches.
- Recommendations include enhanced preoperative risk assessment, extended postoperative monitoring, and exploring alternative analgesics and less invasive surgical techniques to minimize opioid-related risks.
Purpose Of Review:
To summarize recent evidence-based data regarding outcomes associated with children who have obstructive sleep apnea (OSA).
Recent Findings:
Internet surveys conducted by pediatric otolaryngologists and pediatric anesthesiologists have reported a disturbing number of deaths within 24 h of tonsillectomy attributed to postsurgical/anesthesia apnea. Several occurred in the post anesthesia care unit after routine monitors had been removed. In addition, a number of deaths also have been attributed to children who have duplicated cytochromes allowing the rapid conversion of codeine to morphine, thus producing a relative drug overdose. Finally, there is some human and animal evidence suggesting that repeated episodes of hypoxemia result in altered opioid receptors causing relative opioid sensitivity. These factors have important clinical implications.
Summary:
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.
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