Original Article
Rajeev Subramanyam, Paul Willging, Lili Ding, Gang Yang, Anna Varughese. Factors Associated With Post-Adenotonsillectomy Unexpected Admissions in Children. Anesth Analg 2021 Jun 1;132(6):1700-1709. PMID: 32833717
The Cincinnati Children’s Hospital has one of the largest pediatric otolaryngology (“ENT”) practices in America (maybe the world?). In many ways it sets the standard for pediatric ENT surgery and anesthesia, from complex tracheal reconstruction to bread-and-butter adenotonsillectomy (T&A). So, this paper comes from the “Mecca” and has much information to digest. We are going to highlight the key points of the article AND will challenge you with our personal opinions as well. Obviously, our opinions are our own and may not reflect yours. In fact, we don’t always agree with each other either! Myron admittingly is becoming a curmudgeon (“one of the 2 guys in the balcony in the Muppets show”) and Mel represents the newer wave of multidisciplinary-valuing, Aerodigestive-loving, open airway anesthesiologists. So, take the editorial comments today with a grain of salt (or 2!). Indeed, one of the virtues of the PAAD and Ron Litman’s vision of what PAAD should be is the ability to editorialize from experience, exactly as we are doing today.
In the U.S., T&As are amongst the most common surgeries performed in children. The number quoted in the paper “1 in 8 children in the US” is truly unbelievable, particularly if, as the paper says, “the most common indication is for “obstructive sleep apnea/OSA” (or maybe better said “sleep disordered breathing/SDB”). Before going into the details of their findings of factors associated with post T&A admission, we think it’s worth taking a step back to discuss the actual indications for T&A and their definitions – and how our patients arrive at these “diagnoses”. We believe that the diagnosis of OSA (or SDB) as the indication is way overcalled (actually, Myron thinks it’s mostly B.S.) and instead serves as a strategy to get insurance companies to pay for these procedures, procedures which may be unnecessary. Yes, a dark and twisty outlook! Mel tends to want math and data to back up her dark and twisty. So, what we do know as fact: in this study, only 6.6% of patients had OSA documented by polysomnography (PSG)– which is also true for our overall preop population. Mel suspects that given the nature of the “Mecca” (access to a dedicated sleep lab, experience navigating the health care system and insurance world, contracts with large insurers), 6.6% may actually be higher than the average pediatric medical population. We know that very few children actually undergo PSG, which is the diagnostic gold standard. The remainder of the diagnoses are “clinical” – based on history and physical, reports from parents to their physician. Last time we checked, a parent thinking and reporting that their child snores and is a restless sleeper is not a diagnosis! So, why are we operating on and anesthetizing electively without a diagnosis?!?
But wait, it gets worse. Of those 6.6% of kids who underwent PSG in this study, a quarter of them were not diagnosed with OSA – it was ruled out! – and they still had surgery anyway! Really!?! Sooooo, we are now going to ignore the diagnostic gold standard results (no OSA) and put a child through a moderate-to-severely painful surgery for which the diagnosis was ruled out?!?! This should be a clarion call issue for all of us, and we need to get comfortable with the uncomfortable questions: “How many of these T&As are actually necessary?” Furthermore, “Does our vested interest in making the perioperative space a profitable one for our departments and our institutions actually blind us to the lack of necessity of these surgical procedures”? And finally, “What is our duty to ask these hard questions?”
OK, we are now off the soap box. Putting the larger questions aside, certainly these patients will be on your OR schedule for years to come. So, let’s learn how to take the best possible care of them. In this paper, the authors found that there were 4 major independent causes of readmission following T&A: bleeding, inadequate pain relief, dehydration, and postoperative nausea and vomiting. Indeed, inadequate pain relief and the need for IV analgesics in the PACU were the most common PACU adverse events noted as well. Are any of you surprised by these findings? (or from the movie Casablanca “I’m shocked, just shocked, that there is gambling going on here”).
To be honest, we are not surprised. We are unsure when this study was performed. We do know that it was registered in 2012 with clinicaltrials.gov (something for which the investigators should be highly applauded!) and both Rajeev and Anna no longer work at Cincinnati. So, some of these issues involving analgesia may be different than current practice at the Mecca. We suspect that the movement away from opioids both intra-and post-operatively may have the unintended consequence of higher rates of inadequate pain relief and the need for IV analgesics in the PACU. One place to seek comparative data on current 2021 rates of readmission may be from our friends in Seattle, where opioids for T&A are now very uncommon. Inadequate pain relief and dehydration are connected, really a vicious cycle. If one is in too much pain to swallow, dehydration is predictable and expected, staying on a pain medication schedule will be more difficult, and further dehydration will ensue. Further, the failure or limitation to provide opioids in this population may be due to underlying concerns with OSA, which as discussed above may be a significant overcall. Finally, for the millions (millions!!!) of T&As done each year, isn’t it time that we have a better understanding of how to treat pain in these patients?
In this study, overnight inpatient monitoring occurred for children aged <3 years, severe OSA (apnea-hypopnea index ≥10, SPO2 nadir <80%, or both), complicated medical histories, obesity, and certain behavioral criteria. The authors found that some of the predictors of unplanned admission included long term home medications, premedication in the preadmission area with albuterol and/or midazolam, dermatologic (particularly eczema) or neurologic co-morbidity, and IV induction. Interestingly, intraoperative IV acetaminophen reduced the risk of readmission. To be honest, few of these findings are intuitive and the best thing about this paper is that, in some ways, the authors’ hard work raises more questions than answers and will hopefully spur further investigation to validate their findings.
Let us know what you think.
Myron Yaster, MD and Melissa Brooks Peterson, MD
I find the association between premedication with albuterol and unplanned admission controversial. There is a recent randomized clinical study by Dr. Britta S von Ungern-Sternberg that compared albuterol vs placebo with a marked decrease in perioperative respiratory adverse events with the use of two puffs of albuterol 20 minutes prior to admission to the operating room. I have not read the article but is it retrospective? to know the strength of these associated factors. Thanks
Lina