Death after tonsillectomy related to haemorrhage may not be preventable. But death due to apnoea is preventable. More considered management is needed since: 10 deaths occurred at home, 2 in PACU and 3 in wards within 24 hrs of operation. These children could be saved by proper monitoring during operation night. Be aware of marked opioid sensitivity; reduce the dose by 50%. Codeine is to be avoided; Use NSAID, Dexamethasone. Develop an improved safety net for these high-risk children. High-risk patient : Nurse = 2 : 1

1. Perioperative
considerations for
OSA in Children
Lt Col Md Rabiul Alam
MBBS, MCPS, FCPS
Classified Anaesthesiologist
Dept of Anaesthesiology
Combined Military Hospital Dhaka, Bangladesh

2. Introduction
• Now-a-days, OSA has become a “major public health concern”
• Incidence & severity have increased in spikes with the ‘obesity epidemic’
• Recognised now as a “common disorder in children”
• Associated with significant morbidity

3. Introduction (Continued)
• In young children, adenotonsillar hypertrophy is the most common
anatomical abnormality associated with OSA
• Adenotonsillectomy (ADTx) is the most common surgical intervention
• Periop complications are more common in children with severe OSA
• A thorough understanding of -
• Pathophysiology of OSA
• Careful & complete preop assessment
• Meticulous intraop and postop Mx
• Early recognition of potential periop complications
are essential for better outcomes

5. Epidemiology
• The prevalence of OSA in children is 1–4%
• Primary snoring is more common with an incidence as high as 20%
• More common in boys and children who are obese
• Peaks are in between 2 to 8 years of age; declines in the olders
• 2nd increase is seen in adolescence; is associated with obesity
• This peak corresponds to the age range where adenotonsillar
hypertrophy is most commonly observed
• Strong association between family history of OSA and potentially life-
threatening infantile OSA

6. Pathophysiology
Structural
factors:
• Adenotonsillar
hypertrophy
• Craniofacial
abnormality
• Obesity
Neuromotor
tone:
• Cerebral palsy
• Hereditary
diseases
Other factors:
• Genetic
• Hormonal
• ? Diet/Lifestyle
• Ethnicity
• Inflammation
• Passive
smoking
OSA

7. Diagnosis

8. Diagnosis (Continued)
OSA severity by PSG in children and adults as defined by the ASA
Task Force on Periop Mx of Patients with OSA. AHI:
Apnoea/hypopnoea index.
Modified from Practice Guidelines for the Periop Mx of Patients
with OSA by the ASA

9. Diagnosis (Continued)
Sagittal midline fast gradient MRI images obtained during
A: Expiration: Retroglossal airway (arrows) is patent
B: Inspiration: Glossoptosis
Intermittent collapse of retroglossal airway
(arrows).
Ciné MRI sleep studies

10. Diagnosis (Continued)
Clinically:
• Behavioural and neurocognitive disorders
• Poor school performance
• 2ndary Enuresis
• Headaches
• Cardiovascular sequelae: systemic and pulmonary hypertension
• Parental reports alone do not distinguish OSA from simple primary snoring
• Clinical evaluation of paediatric OSA contributes very poor accuracy
• Gold standard: Polysomnography (PSG)

11. Anaesthetic plan
• Readily accessible medical records
• A thorough medical history
• Review of systems
• Careful attention to clinical risk
factors
• A targeted physical examination

12. P/A Check up
• History
• Family history of OSA
• Primary care providers do not routinely screen patients for OSA
• Strive to identify these individuals before surgery by asking
about:
• Snoring
• Be attentive to extremes of body habitus
• Failure to thrive in infants and children
• Obesity

13. Signs & Symptoms
A description of S/S of OSA was published in BMJ in 19th century:
• “the stupid-lazy child
• who frequently suffers from headaches at school,
• breathes through his mouth instead of his nose,
• snores and is restless at night, and
• wakes up with a dry mouth in the morning,
• is well-worthy of the attention of the school medical officer”
Ref: Hill W. On some causes of backwardness and stupidity in children: and the relief of these
symptoms in some instances by naso-pharyngeal scarifications, Br Med J 1889;2:711-2

14. Follow up questions
• A review of associated symptoms
• Daytime sleepiness
• Restless sleep
• Episodes of apnoea
• Paradoxical breathing
• Mouth breathing
• Night-time sweating
• Sleeping in unusual positions
• Parasomnias (sleep terrors, sleep
walking)
• Secondary nocturnal enuresis
• Lack of concentration
• Neurobehavioural disturbances

15. A diagnosed case of OSA
• Review its severity and current
management
• Home monitoring
• Supplemental oxygen administration
• Positioning during sleep
• Airway adjuncts such as BiPAP or
CPAP: current settings
• Device(s) be available during recovery
from anaesthesia

16. Imp findings during Physical
Exam
• Presence of mouth breathing
• Elongated facies
• Chest retractions
• Obesity
• Failure to thrive
• Size of the Tonsils
• Micrognatia
• Macroglossia
• Midface hypoplasia
• Associated syndromes:
• Pierre Robin sequence
• Goldenhar syndrome
• Treacher Collins syndrome
• Hunter and Hurler syndromes
• CHARGE:
• Coloboma
• Heart defect
• Atresia choanae
• Retarded growth and development
• Genital abnormality
• Ear abnormality

17. Investigations
• Preop PSG is rarely performed
• Compensatory metabolic alkalosis suggests chronic hypercarbia
• AHI, drops and duration of desaturation
• Peak end-tidal carbon dioxide
• Inv for PH or Cor pulmonale
• ECG
• Echo
• Evaluation by a Cardiologist

18. PSG
• EEG (encephalo)
• EOG (oculo)
• EMG (myo)
• ECG (cardio)
• Oronasal airflow
• Pulse oximetry
• Respiratory efforts
• Snoring
• Position
• Leg movements

19. Normal PSG

20. Hypopnoea
Reduction in airflow compared to baseline, associated with desaturation

21. Obstructive apnoea
Complete cessation of airflow despite efforts to breathe

22. Real time OSA video

23. Anaesthetic
Considerations

24. Premedication
• Avoidance of all sedative premedication
• Residual periop sedatives may exacerbate postoperative respiratory
depression and increase the likelihood of complications

25. Intra-op Mx
• No consensus yet regarding the anaesthetic Mx in children with OSA
presenting for ADTx
• Opioid and sedative sparing anaesthesia
• Careful titration of relatively shorter acting anaesthetic agents
• Standard monitoring
• Extreme vigilance
• Severe airway obstruction can occur even at light levels of anaesthesia
• Appropriate airway management tools

26. Induction
• Inhalational induction often leads to early & significant airway obstruction
• Ketamine or dexmedetomidine are the drug of choice
• Co-administration of ketamine with glycopyrrolate is better choice
Respiratory depression
Increased pharyngeal collapse
Exacerbation of obstructive
apnoea
• Benzodiazepines
• Barbiturates
• Propofol
• Opioids

27. Analgesic Issue
• Increased sensitivity to OPIOIDs in children with OSA is well known
• Different central and peripheral mechanisms + an up-regulation of μ-opioid
receptors
• 50% of usual dose with careful titration are recommended
• Short-acting agents are preferred over long-acting
• Remifentanil with minimal residual effects, it is an attractive option
• NON-OPIOID analgesic adjuncts:
• Dexamethasone 0.0625–1 mg kg−1
• Ketamine 0.1–0.5 mg kg−1
• Acetaminophen 10–15 mg kg1
• Dexmedetomidine 0.5 μg kg−1 single dose during ADTx can decrease the incidence
of emergence delirium and improve

28. Post-op Care
• Anaesthetist & Surgeon should discuss to select the right tare of postop
care
• Incidence of respiratory complications is as high as 27%
• Recurrent episodes of apnoea, hypopnea, desaturation, and hypercarbia
• Abnormal ventilatory responses to hypoxaemia and hypercapnia
• Recovery of a normal ventilatory drive responses can take weeks
• Postop use of BiPAP/CPAP at the preop settings might be needed
• Avoidance of opioids
• NSAID is advocated with no increase of post-tonsillectomy bleeding
• Continuous monitoring is essential (Patient : Nurse = 2 : 1)

29. Post-ADTx monitoring
• As with the high risk of postop respiratory complications in children with
OSA, continuous monitoring of ventilation and oxygenation is crucial
• Recovery from anaesthesia can be problematic for children with OSA
• Continuous pulse oximetry
• Respiratory rate
• Transcutaneous CO2 monitoring
• Transthoracic impedance (TI)
• Nasal capnography

30. Post-ADTx monitoring (Continued)
Acoustic sensor monitoring with a sensor placed in a
child's neck
[Acoustic respiratory monitoring; Masimo Corporation®, Irvine, CA,
USA]

31. The Outcomes

32. These
cases
occurred
in 1990 to
2010

33. Key points of the Study
Period of Study = 1990-2010
Survey sent to SPA members = 2377
Replies = 731
Identified = 129
Inclusion criteria meet = 92
Identified from ASA Closed Claims Project = 45
Inclusion criteria meet = 19
Final analysis 92 + 19 = 111
Death and permanent neurologic injury occurred in = 86 (77%)
Incidents occurred in OR, PACU, in the ward, and at home
ASA criteria for OSA fulfilled = 63 (57%)

34. Adverse events following ADTx

35. Key points
Demography, Indications of Surgery &
Comorbidities
Children at risk for OSA
(n=63)
All other Children
(n=48)
Age 6.2  3.9 7.0  4.6
Age group (4-8 years) 48% 52%
Ethnicity: African American 32% 6%
ASA II 57% 13%
Indication of Surgery: OSA 71% 0%
Recurrent tonsillitis + Airway obstruction 14% 35%
Airway obstruction / Noisy breathing 14% 13%
Recurrent tonsillitis 0% 17%
Comorbidities: Obesity 46% 6%
Pulmonary 10% 8%
Developmental delay 6% 4%
Congenital syndromes 6% 4%
Bleeding diathesis 5% 4%

36. Adverse events following ADTx…

37. Adverse events following ADTx…

38. Adverse events following ADTx…

39. Recommendations
The Paeditricians,
Surgeons &
Anaesthesiologist
shave to identify
these factors very
carefully

40. A 6-yr-old Post-
Adenotonsillectom
y Patient
Body Wt=27 Kg
1st POD
Morning at
PACU of
CMH
Dhaka

41. A 5.5-yr-old Post-
Adenotonsillectom
y Patient
Body Wt=34 Kg
1st POD
Morning at
PACU of
CMH
Dhaka

45. Conclusion
• Death after tonsillectomy related to haemorrhage may not be
preventable
• But death due to apnoea is preventable
• More considered management is needed since:
10 deaths occurred at home, 2 in PACU and 3 in wards within 24 hrs
of op
• These children could be saved by proper monitoring during operation
night
• Be aware of marked opioid sensitivity; reduce the dose by 50%
• Codeine is to be avoided; Use NSAID, Dexamethasone

46. Thank you