Observation following tonsillectomy may be inadequate due to silent death

Otolaryngology - Head and Neck Surgery (United States)

Volumn 151, Issue 5, 2014, Pages 709-713

  Baugh, Reginald F ^a  

^a UNIVERSITY OF TOLEDO MEDICAL CENTER   (United States)

Author keywords

central apnea; death; hypoxemia; narcotics; postoperative pain; pulse oximetry; respiratory drive; sleep apnea; sleep disordered breathing; tonsillectomy

Indexed keywords

NARCOTIC AGENT; OPIATE;

AIRWAY MONITORING SYSTEM; AIRWAY OBSTRUCTION; CLINICAL OBSERVATION; DEATH; HUMAN; HYPOXIA; PATHOPHYSIOLOGY; POSTOPERATIVE COMPLICATION; PULSE OXIMETRY; RESPIRATORY DRIVE; SLEEP DISORDERED BREATHING; TONSILLECTOMY; MORTALITY; PAIN; PHYSIOLOGIC MONITORING; POSTOPERATIVE CARE; POSTOPERATIVE COMPLICATIONS;

HUMANS; MONITORING, PHYSIOLOGIC; PAIN; POSTOPERATIVE CARE; POSTOPERATIVE COMPLICATIONS; TONSILLECTOMY;

EID: 84908691548     PISSN: 01945998     EISSN: 10976817     Source Type: Journal    
DOI: 10.1177/0194599814545758     Document Type: Review

References (72)

1. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 ; 145: S1-15
2. McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM. Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 1992 ; 118 (9). 940-943
3. Nixon GM, Kermack AS, McGregor CD, et al. Sleep and breathing on the first night after adenotonsillectomy for obstructive sleep apnea. Pediatr Pulmonol. 2005 ; 39 (4). 332-338
4. Koomson A, Morin I, Brouillette R, Brown KA. Children with severe OSAS who have adenotonsillectomy in the morning are less likely to have postoperative desaturation than those operated in the afternoon. Can J Anaesth. 2004 ; 51 (1). 62-67
5. Goldman JL, Baugh RF, Davies L, et al. Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention. Laryngoscope. 2013 ; 123 (10). 2544-2553
6. Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: Houston, we have a problem!. Anesth Analg. 2014 ; 118: 1276-1283
7. Van Someren VH, Hibbert J, Stothers JK, Kyme MC, Morrison GA. Identification of hypoxaemia in children having tonsillectomy and adenoidectomy. Clin Otolaryngol Allied Sci. 1990 ; 15 (3). 263-271
8. Constantin E, Tewfik TL, Brouillette RT. Can the OSA-18 quality-of-life questionnaire detect obstructive sleep apnea in children?. Pediatrics. 2010 ; 125 (1). e162 - e168
9. Ciszkowski C, Madadi P, Phillips MS, Lauwers AE, Koren G. Codeine, ultrarapid-metabolism genotype, and postoperative death. N Engl J Med. 2009 ; 361 (8). 827-828
10. Catley DM, Thornton C, Jordan C, Lehane JR, Royston D, Jones JG. Pronounced, episodic oxygen desaturation in the postoperative period: its association with ventilatory pattern and analgesic regimen. Anesthesiology. 1985 ; 63 (1). 20-28
11. Jones JG, Sapsford DJ, Wheatley RG. Postoperative hypoxaemia: mechanisms and time course. Anaesthesia. 1990 ; 45 (7). 566-573
12. Rosenberg J, Rosenberg-Adamsen S, Kehlet H. Post-operative sleep disturbance: causes, factors, and effects on outcome. European Journal Anaesthesiol. 1995 ; 10: 28-30
13. Bisgard GE, Neubauer JA Regulation of Breathing. Dempsey J Pack A, ed. New York: Dekker ; 617-668.
14. Katayama K, Sato K, Matsuo H, et al. Changes in ventilatory responses to hypercapnia and hypoxia after intermittent hypoxia in humans. Respir Physiol Neurobiol. 2005 ; 146 (1). 55-65
15. Prabhakar NR, Kline DD. Ventilatory changes during intermittent hypoxia: importance of pattern and duration. High Alt Med Biol. 2002 ; 3 (2). 195-204
16. Nieuwenhuijs D, Bruce J, Drummond GB, Warren PM, Wraith PK, Dahan A. Ventilatory responses after major surgery and high dependency care. Br J Anaesth. 2012 ; 108 (5). 864-871
17. Rosen GM, Muckle RP, Mahowald MW, Goding GS, Ullevig C. Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated?. Pediatrics. 1994 ; 93 (5). 784-788
18. Wilson K, Lakheeram I, Morielli A, Brouillette R, Brown K. Can assessment for obstructive sleep apnea help predict postadenotonsillectomy respiratory complications?. Anesthesiology. 2002 ; 96 (2). 313-322
19. Brown KA, Morin I, Hickey C, Manoukian JJ, Nixon GM, Brouillette RT. Urgent adenotonsillectomy: an analysis of risk factors associated with postoperative respiratory morbidity. Anesthesiology. 2003 ; 99 (3). 586-595
20. NixonGMKermackASDavisGMManoukianJJBrownKABrouilletteRT. Planning adenotonsillectomy in children with obstructive sleep apnea: the role of overnight oximetry. Pediatrics. 2004;113: e19-e25. http://pediatrics.aappublications.org/content/113/1/e19.full.
21. Schroeder JW, Anstead AS, Wong H. Complications in children who electively remain intubated after adenotonsillectomy for severe obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2009 ; 73 (8). 1095-1099
22. Doufas AG, Tian L, Padrez KA, et al. Experimental pain and opioid analgesia in volunteers at high risk for obstructive sleep apnea. PLoS One. 2013 ; 8 (1). e54807
23. Yuan H, Pinto SJ, Huang J, et al. Ventilatory responses to hypercapnia during wakefulness and sleep in obese adolescents with and without obstructive sleep apnea syndrome. Sleep. 2012 ; 35 (9). 1257-1267
24. Waters KA, McBrien F, Stewart P, Hinder M, Wharton S. Effects of OSA, inhalational anesthesia, and fentanyl on the airway and ventilation of children. J Appl Physiol. 2002 ; 92 (5). 1987-1994
25. Brown KA, Laferrière A, Moss IR. Recurrent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid requirement for analgesia. Anesthesiology. 2004 ; 100 (4). 806-810
26. Lindgren C, Grögaard J. Reflex apnoea response and inflammatory mediators in infants with respiratory tract infection. Acta Paediatr. 1996 ; 85 (7). 798-803
27. FrøenJFAkreHStray-PedersenBSaugstadOD. Adverse effects of nicotine and interleukin-1β on autoresuscitation after apnea in piglets: implications for sudden infant death syndrome. Pediatrics. 2000;105(4): e52. http://pediatrics.aappublications.org/content/105/4/e52.full.
28. Hofstetter AO, Herlenius E. Interleukin-1β depresses hypoxic gasping and autoresuscitation in neonatal DBA/1lacJ mice. Respir Physiol Neurobiol. 2005 ; 146 (2-3). 135-146
29. Guerra FA, Savich RD, Wallen LD, et al. Prostaglandin E2 causes hypoventilation and apnea in newborn lambs. J Appl Physiol. 1988 ; 64 (5). 2160-2166
30. Marcus CL, Gozal D, Arens R, et al. Ventilatory responses during wakefulness in children with obstructive sleep apnea. Am J Respir Crit Care Med. 1994 ; 149 (3). 715-721
31. Gozal D, Arens R, Omlin KJ, et al. Ventilatory response to consecutive short hypercapnic challenges in children with obstructive sleep apnea. J Appl Physiol. 1995 ; 79 (5). 1608-1614
32. Busby KA, Mercier L, Pivik RT. Ontogenetic variations in auditory arousal threshold during sleep. Psychophysiology. 1994 ; 31 (2). 182-188
33. Marcus CL, Lutz J, Carroll JL, Bamford O. Arousal and ventilatory responses during sleep in children with obstructive sleep apnea. J Appl Physiol. 1998 ; 84 (6). 1926-1936
34. McNamara F, Issa FG, Sullivan CE. Arousal pattern following central and obstructive breathing abnormalities in infants and children. J Appl Physiol. 1996 ; 81 (6). 2651-2657
35. Shine NP, Coates HL, Lannigan FJ, Duncan AW. Adenotonsillar surgery in morbidly obese children: routine elective admission of all patients to the intensive care unit is unnecessary. Anaesth Intensive Care. 2006 ; 34 (6). 724-730
36. Xie A, Bedekar A, Skatrud JB, Teodorescu M, Gong Y, Dempsey JA. The heterogeneity of obstructive sleep apnea (predominant obstructive vs pure obstructive apnea). Sleep. 2011 ; 34 (6). 745-750
37. Khoo SM, Mukherjee JJ, Phua J, Shi DX. Obstructive sleep apnea presenting as recurrent cardiopulmonary arrest. Sleep Breath. 2009 ; 13 (1). 89-92
38. White DP. Opioid-induced suppression of genioglossal muscle activity: is it clinically important?. J Physiol. 2009 ; 587 (14). 3421-3422
39. Dyken ME, Yamada T, Glenn CL, Berger HA. Obstructive sleep apnea associated with cerebral hypoxemia and death. Neurology. 2004 ; 62 (3). 491-493
40. Wilkinson MH, Berger PJ, Blanch N, Brodecky V. Effect of venous oxygenation on arterial desaturation rate during repetitive apneas in lambs. Respir Physiol. 1995 ; 101 (3). 321-331
41. White DP. Opioid-induced suppression of genioglossal muscle activity: is it clinically important?. J Physiol. 2009 ; 587 (14). 3421-3422
42. Hajiha M, DuBord MA, Liu H, Horner RL. Opioid receptor mechanisms at the hypoglossal motor pool and effects on tongue muscle activity in vivo. J Physiol. 2009 ; 587 (11). 2677-2692
43. VanDercar DH, Martinez AP, De Lisser EA. Sleep apnea syndromes: a potential contraindication for patient-controlled analgesia. Anesthesiology. 1991 ; 74 (3). 623-624
44. Gleeson K, Zwillich CW, White DP. Chemosensitivity and the ventilatory response to airflow obstruction during sleep. J Appl Physiol. 1989 ; 67 (4). 1630-1637
45. Lalley PM. μ-opioid receptor agonist effects on medullary respiratory neurons in the cat: evidence for involvement in certain types of ventilatory disturbances. Am J Physiol Regul Integr Comp Physiol. 2003 ; 285 (6). R1287 - R1304
46. Javaheri S, Smith J, Chung E. The prevalence and natural history of complex sleep apnea. J Clin Sleep Med. 2009 ; 5 (3). 205-211
47. Robinson RW, Zwillich CW, Bixler EO, Cadieux RJ, Kales A, White DP. Effects of oral narcotics on sleep-disordered breathing in healthy adults. Chest. 1987 ; 91 (2). 197-203
48. Raghavendran S, Bagry H, Detheux G, Zhang X, Brouillette RT, Brown KA. An anesthetic management protocol to decrease respiratory complications after adenotonsillectomy in children with severe sleep apnea. Anesth Analg. 2010 ; 110 (4). 1093-1101
49. Catling JA, Pinto DM, Jordan C, Jones JG. Respiratory effects of analgesia after cholecystectomy: comparison of continuous and intermittent papaveretum. Br Med J. 1980 ; 281 (6238). 478-480
50. Mildh LH, Scheinin H, Kirvelä OA. The concentration-effect relationship of the respiratory depressant effects of alfentanil and fentanyl. Anesth Analg. 2001 ; 93 (4). 939-946
51. Wiedemann K, Diestelhorst C. [The effect of sedation on pulmonary function]. Anaesthesist. 1995 ; 44: S588 - S593
52. Yamakage M, Kamada Y, Toriyabe M, Honma Y, Namiki A. Changes in respiratory pattern and arterial blood gases during sedation with propofol or midazolam in spinal anesthesia. J Clin Anesth. 1999 ; 11 (5). 375-379
53. Bouillon T, Bruhn J, Roepcke H, Hoeft A. Opioid-induced respiratory depression is associated with increased tidal volume variability. Eur J Anaesthesiol. 2003 ; 20 (2). 127-133
54. Camporesi EM, Nielsen CH, Bromage PR, Durant PA. Ventilatory CO2 sensitivity after intravenous and epidural morphine in volunteers. Anesth Analg. 1983 ; 62 (7). 633-640
55. Rawal N, Wattwil M. Respiratory depression after epidural morphine - an experimental and clinical study. Anesth Analg. 1984 ; 63 (1). 8-14
56. Sandler AN, Chovaz P, Whiting W. Respiratory depression following epidural morphine: a clinical study. Can Anaesth Soc J. 1986 ; 33 (5). 542-549
57. Ostermeier AM, Roizen MF, Hautkappe M, Klock PA, Klafta JM. Three sudden postoperative respiratory arrests associated with epidural opioids in patients with sleep apnea. Anesth Analg. 1997 ; 85 (2). 452-460
58. Catley DM. Postoperative analgesia and respiratory control. Int Anesthesiol Clin. 1984 ; 22 (4). 95-111
59. Ready LB, Oden R, Chadwick HS, et al. Development of an anesthesiology-based postoperative pain management service. Anesthesiology. 1988 ; 68 (1). 100-106
60. Dempsey JA, Veasey SC, Morgan BJ, O'Donnell CP. Pathophysiology of sleep apnea. Physiol Rev. 2010 ; 90 (1). 47-112
61. Brown KA. Outcome, risk, and error and the child with obstructive sleep apnea. Paediatr Anaesth. 2011 ; 21 (7). 771-780
62. Lichtenstein DR, Jagannath S, Baron TH, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008 ; 68 (5). 815-826
63. Waugh JB, Epps CA, Khodneva YA. Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis. J Clin Anesth. 2011 ; 23 (3). 189-196
64. Tate N. Deaths from tonsillectomy. Lancet. 1963 ; 2 (7317). 1090-1091
65. Alexander DW, Graff TD, Kelley E. Factors in tonsillectomy mortality. Arch Otolaryngol. 1965 ; 82 (4). 409-411
66. Davies DD. Anaesthetic mortality in tonsillectomy and adenoidectomy. Br J Anaesth. 1964 ; 36 (2). 110-114
67. Pratt LW. Tonsillectomy and adenoidectomy: mortality and morbidity. Trans Am Acad Ophthalmol Otolaryngol. 1970 ; 74 (6). 1146-1154
68. Pratt LW, Gallagher RA. Tonsillectomy and adenoidectomy: incidence and mortality, 1968-1972. Otolaryngol Head Neck Surg (1979). 1979 ; 87 (2). 159-166
69. Borgbjerg FM, Nielsen K, Franks J. Experimental pain stimulates respiration and attenuates morphine-induced respiratory depression: a controlled study in human volunteers. Pain. 1996 ; 64 (1). 123-128
70. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 ; 144: S1 - S30
71. US Food and Drug Administration. Post-surgery codeine puts kids at risk. http://www.fda.gov/ForConsumers/ConsumerUpd ates/ucm315497.htm. Updated February20, 2013.
72. Sutters KA, Miaskowski C, Holdridge-Zeuner D, et al. A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy. Clin J Pain. 2010 ; 26 (2). 95-103