Predicting Perioperative Respiratory Adverse Events in Children with Sleep-Disordered Breathing
Myron Yaster MD and Melissa Brooks-Peterson MD
Original Article
Carolyne Pehora, David Faraoni, Soichiro Obara, Reshma Amin, Brenda Igbeyi, Adel Al-Izzi, Aman Sayal, Aarti Sayal, Conor Mc Donnell. Predicting Perioperative Respiratory Adverse Events in Children with Sleep-Disordered Breathing. Anesth Analg 2021 Apr 1;132(4):1084-1091 PMID: 33002926
Children with symptoms of sleep-disordered breathing (SDB) appear to be at risk for perioperative respiratory adverse events (PRAE). Further, these children may be more sensitive to the respiratory-depressant effects of opioids compared with children without SDB, making pain control after surgery risky. Whether to admit these patients after surgery and where they should be admitted or discharged home has always been problematic. Tait et al., at the University of Michigan, have previously developed the STUBR questionnaire to help identify patients at highest risk (PMID: 23551934, 27219118). In today’s PAAD, Pehora et al., from the Hospital for Sick Children, Toronto, developed an assessment tool that might better identify the risk of PRAE. Obviously, this single institution study will require further investigation for validation. With that caveat, they present very interesting results.
This study was performed in children of all ages with documented SDB on polysomnography (PSG) (not the BS of “snores at night”) undergoing all surgical procedures and diagnostic imaging requiring general anesthesia, so not just T&A patients. They identified the following independent risk factors: preoperative treatment with CPAP or BiPAP, preoperative supplemental oxygen requirements, diagnosis of severe OSAS on PSG, history of prematurity, and intraoperative airway management requiring tracheal intubation as predictors for PRAE. In addition, they developed a pediatric SDB stratification score quantifying cumulative risk associated with these factors for children with SDB presenting for GA.
Previous studies in children undergoing T&A identified the following risk factors: age younger than 3 years, severe OSAS on PSG, cardiac complications of OSAS, failure to thrive, obesity, craniofacial disorders, neuromuscular disorders, and presence of respiratory infection. Thus, this study expands our understanding to non-T&A patients, for example, children undergoing GA for imaging studies. Thus, their new tool may provide guidance on “who can go home safely? Who needs to be admitted to the hospital and where in the hospital (PICU, monitored bed, etc) should they be admitted”?
What struck us the most was the need for endotracheal intubation as a key branching deciding point in what to do. In this model, patients at high risk who were intubated for their GA, for whatever reason, need to be admitted whereas those who are not (e.g., MRI) do not.
This assessment tool and stratification score can be invaluable if validated in larger, multi-institutional studies and hopefully our colleagues in the Society for Pediatric Anesthesia’s quality and safety and informatics committees can take this on.
Myron Yaster MD and Melissa Brooks-Peterson MD