From Lynn Martin MD MBA, Daniel Low MBBS, and Todd Glenski MD MSHA
We read with interest the editorial by Drs. Yaster and Maxwell and the original article by Efune et al.1 highlighted in the PAAD on October 1, 2024. This team completed a small (n=60) prospective observational cohort study of high-risk patients (age <3 years, BMI >98%tile, and/or severe OSA [apnea-hypopnea index 10)]) undergoing adenotonsillectomy (T&A). They used respiratory volume monitoring (RVM) were tidal volume, respiratory rate, and minute ventilation are continuously measured via respiratory impedance (inductance) plethysmography in the PACU. The investigators found that nearly two thirds of the patients (39/60) had documented PACU respiratory depression via RVM while only one third of patients (21/60) had clinically apparent PACU respiratory events. Additionally, 20/21 (95%) of patients with no respiratory depression in the PACU had no clinically significant events during the postoperative stay.
There were notable limitations with the study. Not only was the anesthetic management left to the discretion of the anesthesiologists, but there was also limited reporting of one significant known risk factor for respiratory depression (i.e., opioids). We do know that 19/60 (32%) of patients received a premedication that included an oral opioid. We also know how much opioids (in oral morphine equivalents mg/kg) patients received (median and range) during the three phases of care: preoperatively (0.0, 0.0-0.2), intraoperatively (0.3, 0.0-0.8), and postoperatively in the PACU (0.1, 0.0-0.6). Unfortunately, we do not know how many patients received intraoperative or postoperative opioids and whether the group receiving opioids had a higher rate of respiratory depression by RVM or clinical assessment.
Why not attempt to avoid this risk factor all together! Seattle Children’s has previously published multiple manuscripts on our now routine practice of opioid-free anesthesia (OFA) for adenotonsillectomy patients.2 The foundation of this approach is the use of multimodal analgesia. We utilize ongoing monitoring of our daily outcomes so we can continuously learn and further improve. Last year we published a 5-year summary of these efforts in which 41,260 ambulatory and hospitalized patients received OFA.3 We now have over 60,000 patients who have received OFA at our hospital and ASC without any detectable adverse effects. Recently we provided additional evidence for this procedure and patient population (n=5,654) where this optimized perioperative (anesthesiology, otolaryngology, and nursing) practice improved our primary outcome (need for morphine in PACU below our target of 10%) without change maximum pain scores (mean 3.6) using preoperative acetaminophen, intraoperative dexmedetomidine, ketamine, and ketorolac, and postoperative prn treatment with dexmedetomidine.4 This regiment did significantly alter one balancing measure; mean PACU (phase 1&2) length of stay increased from 72 to 82 minutes.
The annotation on this chart represents the series of improvement events that led to this improved outcome. In this publication we describe how we were able to safely avoid hospital admission for 75 patients with severe OSA (AHI 10) undergoing T&A who typically would be hospitalized overnight by providing OFA.
Finally, we are eager to spread this practice to other willing centers in the hopes of replicating our success and identifying opportunities for further improvements in a collaborative effort. Following the lead of the very successful Project Spruce (greenhouse gas emission),5 we are planning to use the same format for both internal (real time data access) and external (group) learning for adenotonsillectomy care. The Consortium of Improvement for Tonsillectomy and Adenoidectomy (CITA) will be led by Jake Dahl MD, PhD, MBA (Otolaryngology division chief at Children’s Mercy Kansas City) and a yet to be named anesthesiologist co-PI. We are actively recruiting centers who wish to join Seattle Children’s, Children’s Minnesota, and Children’s Mercy Kansas City in CITA. If you would like to learn more about CITA and consider possible participation, please feel free to email any one of us for more information. Who knows, perhaps we will assess the effectiveness of honey.6
Lynn D. Martin, MD MBA lynn.martin@seattlechildrens.org
Daniel K. Low, MBBS daniel.low@seattlechildrens.org
Todd A. Glenski, MD MSHA tglenski@cmh.edu
References
1. Efune PN, Pinales P, Park J, et al. Pediatric obstructive sleep apnea: a prospective observational study of respiratory events in the immediate recovery period after adenotonsillectomy. Anaesth Crit Care Pain Med 2024;43(4):101385. (In eng). DOI: 10.1016/j.accpm.2024.101385.
2. Franz AM, Dahl JP, Huang H, et al. The development of an opioid sparing anesthesia protocol for pediatric ambulatory tonsillectomy and adenotonsillectomy surgery-A quality improvement project. Paediatr Anaesth. 2019;29(7):682-689. doi:10.1111/pan.13662. (PMID: 31077491).
Martin LD, Franz AM, Rampersad SE, et al. Outcomes for 41 260 pediatric surgical patients with opioid-free anesthesia: One center's experience. Paediatr Anaesth. 2023;33(9):699-709. doi:10.1111/pan.14705. (PMID: 37300350).
Chiem JL, Franz AM, Hansen EE, et al. Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving with real-world data. Pediatr Anesth 2024, Epub Aug 30 ,2024. doi:10.1111/pan.14979.
Project Spruce Consortium. Reducing greenhouse gas emissions from inhaled anesthetics by more than 1 million kilograms of carbon dioxide equivalents. Society for Pediatric Anesthesia 2024 abstract SO1-230.
Yeoh MF, Sommerfield A, Sommerfield D, von Ungern-Sternberg BS. The use of honey in the perioperative care of tonsillectomy patients – A narrative review. Pediatr Anesth 2024; 34:988-98. Doi:10.1111/pan.14938.
From Dixon C Tembo, Consultant Anaesthesiologist, Beit Cure Children’s Hospital Lusaka Zambia on Airway Infections and In-Hospital Complications in Cleft Lip and Palate
Practicing in a resource constrained environment introduces additional concerns, especially post operatively. Patients come from long distances and therefore admission is a non-brainer. potential for complications in the immediate post-op period, apart from airway infections such as wound bleeding (both primary and secondary) would preclude or delay discharge.
From Gavin Jones MBBCh (WITS), FRCA (UK), MBA (UCT), FCA (SA), MMed (UKZN), private practice Cape Town, South Africa as an anaesthesiologist.
I am a volunteer with Operation Smile but also the RMO (Regional Medical Officer) for SSA (Sub-Sharan Africa). I participate in short term surgical programs (previously called missions) for an organization called Operation Smile. We admit children post palate repair in the hospital overnight and then move them to our patient shelter the following day where they stay until the end of the program. Those who have a cleft lip repair are also usually kept in hospital for one night.