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Outcomes intensive care unit placement following pediatric adenotonsillectomy
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109736
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Outcomes intensive care unit placement following pediatric adenotonsillectomy
T
David Z. Allena, Noah Worobetzb, Jordan Lukensc, Cameron Sheehand, Amanda Onwukae, Ryan M. Dopirakf, Tendy Chiangb, Charles Elmaraghyb,∗ a
The Ohio State College of Medicine, Columbus, OH, USA The Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA c The Ohio State University, Columbus, OH, USA d The Department of Otolaryngology, Baylor College of Medicine, Houston, TX, USA e The Center for Surgical Outcomes and Research, Nationwide Children's Hospital, Columbus, OH, USA f Miami University, Oxford, OH, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Pediatric Adenotonsillectomy Intensive care Polysomnogram
Introduction: Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care. Methods: This is a retrospective chart review from the years of 2009–2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU. Results: There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p < 0.0001), and more severe classifications of OSA (p < 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p < 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement. Conclusions: This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.
∗
Corresponding author. E-mail address: [email protected] (C. Elmaraghy).
https://doi.org/10.1016/j.ijporl.2019.109736 Received 26 August 2019; Received in revised form 18 October 2019; Accepted 21 October 2019 Available online 24 October 2019 0165-5876/ © 2019 Published by Elsevier B.V.
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109736
D.Z. Allen, et al.
1. Introduction
intubation. Because all of the patients in the sample were admitted for their AT, we anticipated that complications would be higher than average. Proportions were used to describe the overall rate of complications, and bivariate statistics were used to evaluate the relationship between patient characteristics and complications. Bivariate statistics, including Chi-square tests and Wilcoxon-MannWhitney tests, were used to evaluate these relationships. All statistical analyses were conducted in SAS Enterprise. An alpha level of 0.0004 was applied after a Bonferroni correction for multiple comparisons. During the study period, there were 16,592 AT performed at this institution, of which 14% (n = 2361) were associated with an overnight observation.
Adenotonsillectomy is a common surgery to treat pediatric sleep related breathing issues [1]. While most patients tolerate the operation without issue, there are potential complications with the procedures such as bleeding, respiratory compromise, and pulmonary edema [1]. Complications have been shown to be associated with younger age (< 3), increased body mass index (BMI), Down's syndrome, cerebral palsy and other craniofacial abnormalities [1–6]. Specifically, overnight polysomnography (PSG) findings, such as clinically defined obstructive sleep apnea (OSA), elevated apnea-hypopnea index (AHI) and oxygen desaturation, have also been associated with increased complications in the literature [7–10]. The American Academy of Otolaryngology (AAO) recommends overnight stay for patients < 3 years of age or presenting with severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir < 80%, or both) but does not comment on planned PICU placement [1]. Given the concern for post-operative complications and the need for additional postoperative care, many providers plan for a pediatric intensive care unit (PICU) placement post-operatively for at-risk patients. Yet, there is variable evidence available in the literature as to whether or not planned post-operative PICU placement is necessary, even in high-risk patients. For example, multiple studies have suggested that severe classifications of OSA and higher levels of apnea-hypopnea-indexes (AHI, Respiratory Disturbance Indexes (RDI) and longer time spent below 90% saturation predispose to needing higher levels of care [8,11–13]. However, other studies have suggested that severe classifications of OSA on the sleep study do not predispose to complications [14–16]. Additional insight is needed as PICU placement is associated with an increase in hospital resources and costs [17,18]. The goal of this study is to identify co-morbidities associated with higher level of postoperative care following AT and to evaluate preoperative decision to refer children to the PICU.
3. Results In our matched cohort, three hundred thirty-eight pediatrics patients who were admitted and underwent an AT were included in the study. Approximately half of the patients did not have a PICU stay postoperatively (n = 156), 158 patients did have a planned PICU stay postoperatively, and 24 patients had an unplanned PICU stay post-operatively. The median age of our patients was 5 (IQR: 7). Our study showed a complication rate of 20%, which is significantly elevated than our true rate due to our sampling strategy. Additionally, 26% of the patients in this cohort utilized respiratory support. The prevalence of specific complications is detailed in Table 1. In total we found that 31% of our patients utilized respiratory support or had a complication. Importantly, there were no differences in any demographic population characteristics between the patients who were sent to the floor and those that had planned PICU stays. The median length of stay (LOS) was 1 day with an IQR of 1.0. Overall patients who were referred to the PICU had a complication rate of 32% compared to just 8% of those who went to the floor. Also, those who went to the PICU utilized respiratory support 46% of the time compared to just 8% of the time for those patients who were sent to the floor. Patients who admitted for observation had a median LOS of 1.0 (IQR = 0), while patients who had a planned PICU stay had a median LOS of 2.0 (IQR: 3.0) and patients with an unplanned PICU stay had a median LOS of 2.0 with an IQR of 1.0. Of the patients who were sent to the floor, 92% did not require additional respiratory support or complications compared to 54% of those who had a planned PICU stay. Additionally, none of the patients were discharged on day of surgery; however, 238 (65%) were discharged on the post-operative day one (164 floor, 64 planned PICU, 10 unplanned PICU).
2. Methods All patients under the age of 18 years' old who were admitted for a AT at Nationwide Children's Hospital between 2009 and 2016 were screened for this study. The study population was limited to patients that underwent AT with known obstructive sleep apnea or sleep disordered breathing. Because the intention of the study was to characterize patients observed in the PICU, these patients were oversampled. Half of all patients with an ICU stay were randomly selected for enrollment, and each patient with an ICU stay was matched with one patient who did not have an ICU stay but were admitted to the hospital for post-operatively. Patients were matched on age, sex, payer, year of procedure, and neurologic and congenital comorbidities. Chart reviews were conducted for 338 (158 PICU, 156 floor) participants to assess polysomnography results, comorbidities, details of the surgery, complications, and details of the ICU stay if any. The first goal of the study was to describe the overall populations and detail the frequency of complications and the need for respiratory support. Additionally, we will analyze and evaluate which preoperative characteristics are associated with having an ICU stay. We evaluated features associated with a planned ICU stay, defined as having a preoperative surgery order for ICU placement. Similarly, we evaluated characteristics of patients with an unplanned ICU, who were transferred to intensive care after being admitted to the floor postoperatively. The second goal of the study was to assess risk factors for complications and complexities in this cohort. Complications were defined as any patients who underwent a tracheotomy, experienced adverse bleeding events, underwent a chest radiograph, had atelectasis or pneumonia or pulmonary edema. Respiratory support was defined as needing supplementary oxygen with length of stay (LOS) of more than one day, positive pressure, or
Table 1 Prevalence of complications. Prevalence of Complications Health Care Utilization Tracheotomy Bleeding Chest Xray Atelectasis or Pneumonia Pulmonary Edema More than 1 Day in ICU
N 2 6 39 25 9 36
% 1% 2% 12% 8% 3% 11%
Any Complication
64
20%
49 34 3
15% 10% 1%
Any Respiratory Support
86
26%
Either Respiratory Support or Complication
100
31%
Respiratory Support Intubated Vent Positive Pressure Other Supplementary Oxygen
2
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109736
D.Z. Allen, et al.
among patients with GI comorbidities was 20%, TD comorbidities was 26%, viral infections was 20%, and reflux was 32% compared to just 4%, 7%, 2%,12% respectively (p < 0.004 all). There was no difference in sleep study findings between the two populations. Similarly, there are no population level differences we could detect between patients who require respiratory support post-operatively and those who do not. Patients with planned PICU stays appropriately utilized higher levels of care in comparison to those who did not have planned PICU stays. 46% percent of the planned PICU patients utilized some form of respiratory support and had a complication rate of 32% in comparison to 8% for both in the non-ICU patients (p < 0.0001). More than half of the patients admitted to the PICU did not utilize any form of respiratory support. Additionally, more than 65% (n = 108) of these patients with planned ICU stays did not have any reported complications (Table 3).
Table 2 Characteristics associated with planned ICU. No Planned ICU (n = 180) N Technology Dependent 5 Flag Sleep Disordered 138 Breathing Sleep Study 58 Obstructive Sleep Apnea Mild Moderate Severe Respiratory Effort Related Arousals, Median (IQR) Apneas, Median (IQR) Hypoapneas, Median (IQR) Total Sleep Time, Minutes, Median (IQR) Respiratory Disturbance Index, Median (IQR) Apnea Hypopnea Index, Median (IQR) End-Tidal CO [2], Median (IQR) Lowest O [2] Desaturation, Median (IQR) Percent of the study < 90%, Median (IQR) Respiratory Support Supplementary 5 Oxygen Positive Pressure 9 Intubated Vent 0 Complications 14
Planned ICU (n = 158)
p value
%
N
%
3%
21
13%
0.0006
77%
38
24%
< 0.0001
32%
132
84%
< 0.0001 < 0.0001
16 29 13 30
28% 50% 22% 24
10 14 107 26
8% 11% 81% 24
0.06
2 12 420
6 30 81
27 59 418
54 82 87
< 0.0001 < 0.0001 0.22
7
5
21
21
< 0.0001
2
5
16
22
< 0.0001
50
6
52
8
0.01
86
11
72
24
< 0.0001
0
1
2
9
< 0.0001
4. Discussion
< 0.0001 3%
44
28%
5% 0% 8%
25 3 50
16% 2% 32%
The pediatric ICU is used for patients following adenotonsillectomy for severe comorbidities, post-operative complications, and higher risk patients such as patients with severe OSA. Recent literature has suggested that the ICU may not be required for patients with severe OSA [19]. This is important as PICU is resource intensive and higher cost in comparison to observation. Investigation of utilization of the PICU suggest that nearly 18% of patients sent to the PICU stays were “noncritical” [20]. This investigation details a matched cohort study of AT and the utilization of the PICU at a tertiary free-standing pediatric hospital. 45% of planned PICU patients utilized some form of respiratory support had a complication rate 32% of the time. We also found that PICU planning was associated with higher rates of perioperative sleep studies, severe OSA as measured on polysomnogram and a history of technological dependence. Complications in our planned PICU population were associated with specific clinical histories such as a history of G technology dependence such as a gastrostomy tube, recent viral infection or a history of reflux. Additionally, while there was a small portion of non-ICU patients who experienced complications and had unplanned PICU stays, there were no population differences between the 2 cohorts. Planning for PICU was associated with a history of technology dependence and severe OSA. Review of the literature reports suggests severe OSA and higher levels of AHI are related to post-operative complications [13]. Aside from known risk factors for ICU admission (age, neuro, congenital comorbidities), technology dependence is another key factor that may drive planned ICU stay as preoperative respiratory problems would predict post-operative need for respiratory support. By the nature of this study design, children with an ICU stay after their AT were oversampled, and thus complications and levels of respiratory support are higher than expected. The rate of complications in this study sample was 20%. We found that patients who had a history of gastrointestinal comorbidities, technology dependence, viral infections or GERD had a higher rate of having complications. The relationship between GI comorbidities and complications post-operatively during a T&A has been reported prior [21]. Further, viral infections have been described in the pediatric OSA population before, however, there is no analysis that suggests whether or not it increases the rate of
3.3. Complications in unplanned PICU patients Within our population, 24 patients had unplanned admissions to the PICU (Table 4). These patients often had respiratory issues in the postanesthesia care unit requiring the need for escalated care and transfer. No pre-operative characteristics were significantly different between this group and those sent to the floor. Specifically, 21 out of 24 these 21 (81%) of the PICU patients who had unplanned stays required respiratory support (see Table 5).
< 0.0001
3.1. Characteristics associated with planned ICU stay Compared to non-ICU patients, patients with pre-operatively planned ICU stays had higher rates of technology dependence (TD), sleep studies and a diagnosis of OSA (Table 2). Additionally, patients with planned ICU stays had more severe sleep study readings as well (Table 2). Specifically, 13% patients with planned ICU stays had technological dependence compared to just 3% for patients who did not have a planned ICU stay (p = 0.0006). Patients with planned ICU stays also had OSA 76% of the time compared to just 23% of the time for patients who did not have a planned ICU (77% of these patients had sleep disordered breathing instead). The majority of patients referred to ICU have moderate/severe OSA. Overall, 81% patients with planned ICU stays had severe OSA compared to just 22% in patients with planned ICU stays who received sleep studies (p < 0.0001). Moreover, those who had planned PICU stays also had higher levels of median levels on sleep study such as apneas, hypopneas, RDIs, AHIs, percent of the study spent under 90% oxygenation and a lower oxygen desaturation nadir overnight (p < 0.0001 for all). 3.2. Characteristics associated with complications among planned PICU patients In this population sample, 50 patients in the planned PICU population suffered from a complication following their AT (Table 3). These complications included bleeding, tracheotomy, the need for a chest xray, atelectasis, pneumonia and pulmonary edema. Complications were associated with a younger age, gastrointestinal comorbidities (GI), technological dependence (TD), viral infections (VI), and a history of reflux (RF, Table 3). Specifically, the median age of patients with complications was 3 (IQR: 3) compared to patients with no complications which was 6 (IQR: 7; p = 0.0003). The rate of complications 3
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109736
D.Z. Allen, et al.
Table 3 Characteristics Associated with Complications among Planned PICU patients.
Age, Median (IQR) Body Mass Index, Median (IQR) Gastrointestinal Flag Technology Dependent Flag Viral Infection Reflux Sleep Disordered Breathing Sleep Study Obstructive Sleep Apnea Mild Moderate Severe Respiratory Effort Related Arousals, Median (IQR) Apneas, Median (IQR) Hypoapneas, Median (IQR) Total Sleep Time, Minutes, Median (IQR) Respiratory Disturbance Index, Median (IQR) Apnea Hypopnea Index, Median (IQR) End-Tidal CO [2], Median (IQR) Lowest O [2] Desaturation, Median (IQR) Percent of the study < 90%, Median (IQR)
No Complications (n = 108)
Complications (n = 50)
N
%
N
%
6 22 4 8 2 13 22 91
7 15 4% 7% 2% 12% 20% 84%
3 17 10 13 10 16 16 41
3 5 20% 26% 20% 32% 32% 82%
4 9 77 24 29 65 417 21 16 52 74 2
4% 10% 85% 23 48 74 87 19 19 6 21 6
6 5 30 30 25 34 418 23 15 55 70 3
12% 10% 60% 24 26 97 82 24 27 10 32 15
Table 4 Characteristics associated with unplanned ICU.
Body Mass Index, Median (IQR) Comorbidities Gastrointestinal Flag Technology Dependent Flag Viral Infection Reflux Sleep Disordered Breathing Sleep Study Obstructive Sleep Apnea Mild Moderate Severe Respiratory Effort Related Arousals, Median (IQR) Apneas, Median (IQR) Hypoapneas, Median (IQR) Total Sleep Time, Minutes, Median (IQR) Respiratory Disturbance Index, Median (IQR) Apnea Hypopnea Index, Median (IQR) End-Tidal CO [2], Median (IQR) Lowest O [2] Desaturation, Median (IQR) Percent of the study < 90%, Median (IQR)
p value
0.0003 0.004 0.001 0.001 < 0.0001 0.003 0.11 0.72 0.11
0.67 0.42 0.11 0.62 0.52 0.38 0.11 0.14 0.25
Table 5 Complications in the unplanned PICU population.
No ICU (n = 156)
Unplanned ICU (n = 24)
p value
N
%
N
%
18
8
19
10
0.94
3 6
2% 4%
2 2
8% 8%
0.07 0.30
6 29 125 46
4% 19% 80% 29%
1 7 13 12
4% 29% 54% 50%
0.91 0.19 0.03 0.04 0.03
13 26 7 29
28% 57% 15% 18
3 3 6 32
13% 13% 25% 33
0.47
2 7 418
4 21 90
12 38 427
56 40 103
0.08 0.01 0.56
6
5
12
16
0.03
2
3
7
18
0.01
50
6
50
5
0.84
86
11
81
22
0.21
0
1
1
3
0.03
Unplanned ICU (n = 24)
Respiratory support Supplementary Oxygen Positive Pressure Complications Pulmonary Edema Atelectasis Pneumonia
N
%
21 10
88% 83%
4 7 4
17% 29% 17%
these patients could be due to pre-existing respiratory issues. Interestingly, we did not observe that more severe delineations of OSA and higher measurements on the sleep study were associated with complications. These results mirror those of del-Río et al., 2014, which supported that severe OSA does not indicate a higher rate of complications and thus higher levels of care [25]. Additionally, the findings that specific readings (AHI, RDI, etc) do not affect complication rates also validate prior research from Konstantinopoulou et. al. 2016 while refuting Thongyman et. al. 2014 [13,16]. Our study suggests that providers should be focused on planning for elevated levels of hospital care if the patient has a clinical history consistent with risk factors identified in this paper and not the severity of OSA as classified by the sleep study. This study is not without limitations. This is a single institution study, thus limiting the external validity of this investigation. Additionally, our hospital does not have a step-down unit from the PICU. The optimal study design to assess preoperative characteristics and the risk of complications following AT would be a prospective study where all patients underwent preoperative PSG. The absence of a PSG study in 52% of the sample population prevented an analysis of thresholds that would be appropriate for planned ICU stay postoperatively. A second limitation is that preoperative planning for PICU following AT is likely the result of individual provider decision making, which may vary across providers and also institutions. As a result, additional research is necessary to better understand the role of ICU referral postoperatively for AT and potential risks and benefits associated with ICU referral.
complications in the pediatric OSA population [22]. Yet, there is some analysis that suggests that perioperative viral infections do increase the rate of complications in pediatric patients undergoing surgery [23]. Additionally, a history of reflux has also been described before as a risk factor for complications following an AT, thus our findings validate this prior research [24]. Technological dependence is a term associated with the use of CPAP at home and its association with post-operative complications has not been well studied. The increased complication rate in 4
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109736
D.Z. Allen, et al.
5. Conclusion OSA severity as measured by PSG was not associated with a higher rate of complications in our study. Providers should plan for higher levels of hospital care for younger patients or those with a history of GI comorbidities, technology dependence, recent viral infection or reflux, as these were shown to be associated with higher rates of complications.
[11]
[12]
[13]
Disclosures [14]
C. Elmaraghy, Smith and Nephew: Consultant. Appendix A. Supplementary data
[15]
Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ijporl.2019.109736.
[16]
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Outcomes intensive care unit placement following pediatric adenotonsillectomy
T
David Z. Allena, Noah Worobetzb, Jordan Lukensc, Cameron Sheehand, Amanda Onwukae, Ryan M. Dopirakf, Tendy Chiangb, Charles Elmaraghyb,∗ a
The Ohio State College of Medicine, Columbus, OH, USA The Department of Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA c The Ohio State University, Columbus, OH, USA d The Department of Otolaryngology, Baylor College of Medicine, Houston, TX, USA e The Center for Surgical Outcomes and Research, Nationwide Children's Hospital, Columbus, OH, USA f Miami University, Oxford, OH, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Pediatric Adenotonsillectomy Intensive care Polysomnogram
Introduction: Adenotonsillectomy (AT) is the most common surgical procedure for the treatment of sleep related breathing issues in children. While overnight observation in the hospital setting is utilized frequently in children after a AT, ICU setting is commonly used for patients with sleep apnea. This objective of this study is to examine factors associated with the preoperative decision to admit patients to PICU following AT as well as co-morbidities that may justify necessity for higher level of care. Methods: This is a retrospective chart review from the years of 2009–2016. All patients who underwent AT for known sleep-related breathing issues at Nationwide Children's Hospital were eligible for inclusion. A complication was defined as an adverse event such as pulmonary edema, re-intubation, or a bleeding event. Respiratory support was defined as utilizing supplementary oxygen for more than one day, positive pressure ventilation, or intubation. Proportions and medians were used to describe the overall rate of complications/complexities in care, and bivariate statistics were used to evaluate the relationship between patient characteristics and outcomes. Similar methods were used to evaluate factors associated with preoperative referral to the PICU. Results: There were 180 patients admitted to hospital in non-ICU setting and 158 patients with a planned PICU stay. The patients with planned PICU stays had higher rates of technological dependence (13% vs. 3%; p = 0.0006), perioperative sleep studies (80% vs. 29%; p < 0.0001), and more severe classifications of OSA (p < 0.0001). Patients with planned ICU placement also had higher rates of apneas, hypopneas, respiratory disturbance indexes, apnea hypopnea indexes, lower oxygen saturation nadirs, and a longer time spent below 90% oxygenation in sleep studies (p < 0.0001). Nearly 45% of the patients with planned ICU stays required respiratory support compared to just 8% of non-PICU patients. Additionally, 32% of the patients with planned ICU stays experienced complications compared to just 8% of the floor population. Complications were associated with younger ages, gastrointestinal comorbidities, technological dependence, viral infections, and a history of reflux. Interestingly, there were no differences in the complication rate by sleep studies findings. Similarly, there were no population level differences between patients who required respiratory support in the ICU and those that did not. Unplanned PICU placement was a rare but significant adverse event (n = 24). None of the hypothesized risk factors were associated with unplanned PICU placement. Conclusions: This study suggest that while our pre-operative referral program for PICU placement is effective in identifying patients needing higher levels of care, the program places many patients in the PICU who did not utilize respiratory support or suffer from complications. We observed some misalignment between characteristics associated with planned ICU stays and actual complications. This suggests that patients with specific clinical histories, not findings on their sleep studies, should be prepared to receive higher levels of care.
∗
Corresponding author. E-mail address: [email protected] (C. Elmaraghy).
https://doi.org/10.1016/j.ijporl.2019.109736 Received 26 August 2019; Received in revised form 18 October 2019; Accepted 21 October 2019 Available online 24 October 2019 0165-5876/ © 2019 Published by Elsevier B.V.
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109736
D.Z. Allen, et al.
1. Introduction
intubation. Because all of the patients in the sample were admitted for their AT, we anticipated that complications would be higher than average. Proportions were used to describe the overall rate of complications, and bivariate statistics were used to evaluate the relationship between patient characteristics and complications. Bivariate statistics, including Chi-square tests and Wilcoxon-MannWhitney tests, were used to evaluate these relationships. All statistical analyses were conducted in SAS Enterprise. An alpha level of 0.0004 was applied after a Bonferroni correction for multiple comparisons. During the study period, there were 16,592 AT performed at this institution, of which 14% (n = 2361) were associated with an overnight observation.
Adenotonsillectomy is a common surgery to treat pediatric sleep related breathing issues [1]. While most patients tolerate the operation without issue, there are potential complications with the procedures such as bleeding, respiratory compromise, and pulmonary edema [1]. Complications have been shown to be associated with younger age (< 3), increased body mass index (BMI), Down's syndrome, cerebral palsy and other craniofacial abnormalities [1–6]. Specifically, overnight polysomnography (PSG) findings, such as clinically defined obstructive sleep apnea (OSA), elevated apnea-hypopnea index (AHI) and oxygen desaturation, have also been associated with increased complications in the literature [7–10]. The American Academy of Otolaryngology (AAO) recommends overnight stay for patients < 3 years of age or presenting with severe OSA (AHI ≥10 obstructive events/hour, oxygen saturation nadir < 80%, or both) but does not comment on planned PICU placement [1]. Given the concern for post-operative complications and the need for additional postoperative care, many providers plan for a pediatric intensive care unit (PICU) placement post-operatively for at-risk patients. Yet, there is variable evidence available in the literature as to whether or not planned post-operative PICU placement is necessary, even in high-risk patients. For example, multiple studies have suggested that severe classifications of OSA and higher levels of apnea-hypopnea-indexes (AHI, Respiratory Disturbance Indexes (RDI) and longer time spent below 90% saturation predispose to needing higher levels of care [8,11–13]. However, other studies have suggested that severe classifications of OSA on the sleep study do not predispose to complications [14–16]. Additional insight is needed as PICU placement is associated with an increase in hospital resources and costs [17,18]. The goal of this study is to identify co-morbidities associated with higher level of postoperative care following AT and to evaluate preoperative decision to refer children to the PICU.
3. Results In our matched cohort, three hundred thirty-eight pediatrics patients who were admitted and underwent an AT were included in the study. Approximately half of the patients did not have a PICU stay postoperatively (n = 156), 158 patients did have a planned PICU stay postoperatively, and 24 patients had an unplanned PICU stay post-operatively. The median age of our patients was 5 (IQR: 7). Our study showed a complication rate of 20%, which is significantly elevated than our true rate due to our sampling strategy. Additionally, 26% of the patients in this cohort utilized respiratory support. The prevalence of specific complications is detailed in Table 1. In total we found that 31% of our patients utilized respiratory support or had a complication. Importantly, there were no differences in any demographic population characteristics between the patients who were sent to the floor and those that had planned PICU stays. The median length of stay (LOS) was 1 day with an IQR of 1.0. Overall patients who were referred to the PICU had a complication rate of 32% compared to just 8% of those who went to the floor. Also, those who went to the PICU utilized respiratory support 46% of the time compared to just 8% of the time for those patients who were sent to the floor. Patients who admitted for observation had a median LOS of 1.0 (IQR = 0), while patients who had a planned PICU stay had a median LOS of 2.0 (IQR: 3.0) and patients with an unplanned PICU stay had a median LOS of 2.0 with an IQR of 1.0. Of the patients who were sent to the floor, 92% did not require additional respiratory support or complications compared to 54% of those who had a planned PICU stay. Additionally, none of the patients were discharged on day of surgery; however, 238 (65%) were discharged on the post-operative day one (164 floor, 64 planned PICU, 10 unplanned PICU).
2. Methods All patients under the age of 18 years' old who were admitted for a AT at Nationwide Children's Hospital between 2009 and 2016 were screened for this study. The study population was limited to patients that underwent AT with known obstructive sleep apnea or sleep disordered breathing. Because the intention of the study was to characterize patients observed in the PICU, these patients were oversampled. Half of all patients with an ICU stay were randomly selected for enrollment, and each patient with an ICU stay was matched with one patient who did not have an ICU stay but were admitted to the hospital for post-operatively. Patients were matched on age, sex, payer, year of procedure, and neurologic and congenital comorbidities. Chart reviews were conducted for 338 (158 PICU, 156 floor) participants to assess polysomnography results, comorbidities, details of the surgery, complications, and details of the ICU stay if any. The first goal of the study was to describe the overall populations and detail the frequency of complications and the need for respiratory support. Additionally, we will analyze and evaluate which preoperative characteristics are associated with having an ICU stay. We evaluated features associated with a planned ICU stay, defined as having a preoperative surgery order for ICU placement. Similarly, we evaluated characteristics of patients with an unplanned ICU, who were transferred to intensive care after being admitted to the floor postoperatively. The second goal of the study was to assess risk factors for complications and complexities in this cohort. Complications were defined as any patients who underwent a tracheotomy, experienced adverse bleeding events, underwent a chest radiograph, had atelectasis or pneumonia or pulmonary edema. Respiratory support was defined as needing supplementary oxygen with length of stay (LOS) of more than one day, positive pressure, or
Table 1 Prevalence of complications. Prevalence of Complications Health Care Utilization Tracheotomy Bleeding Chest Xray Atelectasis or Pneumonia Pulmonary Edema More than 1 Day in ICU
N 2 6 39 25 9 36
% 1% 2% 12% 8% 3% 11%
Any Complication
64
20%
49 34 3
15% 10% 1%
Any Respiratory Support
86
26%
Either Respiratory Support or Complication
100
31%
Respiratory Support Intubated Vent Positive Pressure Other Supplementary Oxygen
2
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109736
D.Z. Allen, et al.
among patients with GI comorbidities was 20%, TD comorbidities was 26%, viral infections was 20%, and reflux was 32% compared to just 4%, 7%, 2%,12% respectively (p < 0.004 all). There was no difference in sleep study findings between the two populations. Similarly, there are no population level differences we could detect between patients who require respiratory support post-operatively and those who do not. Patients with planned PICU stays appropriately utilized higher levels of care in comparison to those who did not have planned PICU stays. 46% percent of the planned PICU patients utilized some form of respiratory support and had a complication rate of 32% in comparison to 8% for both in the non-ICU patients (p < 0.0001). More than half of the patients admitted to the PICU did not utilize any form of respiratory support. Additionally, more than 65% (n = 108) of these patients with planned ICU stays did not have any reported complications (Table 3).
Table 2 Characteristics associated with planned ICU. No Planned ICU (n = 180) N Technology Dependent 5 Flag Sleep Disordered 138 Breathing Sleep Study 58 Obstructive Sleep Apnea Mild Moderate Severe Respiratory Effort Related Arousals, Median (IQR) Apneas, Median (IQR) Hypoapneas, Median (IQR) Total Sleep Time, Minutes, Median (IQR) Respiratory Disturbance Index, Median (IQR) Apnea Hypopnea Index, Median (IQR) End-Tidal CO [2], Median (IQR) Lowest O [2] Desaturation, Median (IQR) Percent of the study < 90%, Median (IQR) Respiratory Support Supplementary 5 Oxygen Positive Pressure 9 Intubated Vent 0 Complications 14
Planned ICU (n = 158)
p value
%
N
%
3%
21
13%
0.0006
77%
38
24%
< 0.0001
32%
132
84%
< 0.0001 < 0.0001
16 29 13 30
28% 50% 22% 24
10 14 107 26
8% 11% 81% 24
0.06
2 12 420
6 30 81
27 59 418
54 82 87
< 0.0001 < 0.0001 0.22
7
5
21
21
< 0.0001
2
5
16
22
< 0.0001
50
6
52
8
0.01
86
11
72
24
< 0.0001
0
1
2
9
< 0.0001
4. Discussion
< 0.0001 3%
44
28%
5% 0% 8%
25 3 50
16% 2% 32%
The pediatric ICU is used for patients following adenotonsillectomy for severe comorbidities, post-operative complications, and higher risk patients such as patients with severe OSA. Recent literature has suggested that the ICU may not be required for patients with severe OSA [19]. This is important as PICU is resource intensive and higher cost in comparison to observation. Investigation of utilization of the PICU suggest that nearly 18% of patients sent to the PICU stays were “noncritical” [20]. This investigation details a matched cohort study of AT and the utilization of the PICU at a tertiary free-standing pediatric hospital. 45% of planned PICU patients utilized some form of respiratory support had a complication rate 32% of the time. We also found that PICU planning was associated with higher rates of perioperative sleep studies, severe OSA as measured on polysomnogram and a history of technological dependence. Complications in our planned PICU population were associated with specific clinical histories such as a history of G technology dependence such as a gastrostomy tube, recent viral infection or a history of reflux. Additionally, while there was a small portion of non-ICU patients who experienced complications and had unplanned PICU stays, there were no population differences between the 2 cohorts. Planning for PICU was associated with a history of technology dependence and severe OSA. Review of the literature reports suggests severe OSA and higher levels of AHI are related to post-operative complications [13]. Aside from known risk factors for ICU admission (age, neuro, congenital comorbidities), technology dependence is another key factor that may drive planned ICU stay as preoperative respiratory problems would predict post-operative need for respiratory support. By the nature of this study design, children with an ICU stay after their AT were oversampled, and thus complications and levels of respiratory support are higher than expected. The rate of complications in this study sample was 20%. We found that patients who had a history of gastrointestinal comorbidities, technology dependence, viral infections or GERD had a higher rate of having complications. The relationship between GI comorbidities and complications post-operatively during a T&A has been reported prior [21]. Further, viral infections have been described in the pediatric OSA population before, however, there is no analysis that suggests whether or not it increases the rate of
3.3. Complications in unplanned PICU patients Within our population, 24 patients had unplanned admissions to the PICU (Table 4). These patients often had respiratory issues in the postanesthesia care unit requiring the need for escalated care and transfer. No pre-operative characteristics were significantly different between this group and those sent to the floor. Specifically, 21 out of 24 these 21 (81%) of the PICU patients who had unplanned stays required respiratory support (see Table 5).
< 0.0001
3.1. Characteristics associated with planned ICU stay Compared to non-ICU patients, patients with pre-operatively planned ICU stays had higher rates of technology dependence (TD), sleep studies and a diagnosis of OSA (Table 2). Additionally, patients with planned ICU stays had more severe sleep study readings as well (Table 2). Specifically, 13% patients with planned ICU stays had technological dependence compared to just 3% for patients who did not have a planned ICU stay (p = 0.0006). Patients with planned ICU stays also had OSA 76% of the time compared to just 23% of the time for patients who did not have a planned ICU (77% of these patients had sleep disordered breathing instead). The majority of patients referred to ICU have moderate/severe OSA. Overall, 81% patients with planned ICU stays had severe OSA compared to just 22% in patients with planned ICU stays who received sleep studies (p < 0.0001). Moreover, those who had planned PICU stays also had higher levels of median levels on sleep study such as apneas, hypopneas, RDIs, AHIs, percent of the study spent under 90% oxygenation and a lower oxygen desaturation nadir overnight (p < 0.0001 for all). 3.2. Characteristics associated with complications among planned PICU patients In this population sample, 50 patients in the planned PICU population suffered from a complication following their AT (Table 3). These complications included bleeding, tracheotomy, the need for a chest xray, atelectasis, pneumonia and pulmonary edema. Complications were associated with a younger age, gastrointestinal comorbidities (GI), technological dependence (TD), viral infections (VI), and a history of reflux (RF, Table 3). Specifically, the median age of patients with complications was 3 (IQR: 3) compared to patients with no complications which was 6 (IQR: 7; p = 0.0003). The rate of complications 3
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109736
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Table 3 Characteristics Associated with Complications among Planned PICU patients.
Age, Median (IQR) Body Mass Index, Median (IQR) Gastrointestinal Flag Technology Dependent Flag Viral Infection Reflux Sleep Disordered Breathing Sleep Study Obstructive Sleep Apnea Mild Moderate Severe Respiratory Effort Related Arousals, Median (IQR) Apneas, Median (IQR) Hypoapneas, Median (IQR) Total Sleep Time, Minutes, Median (IQR) Respiratory Disturbance Index, Median (IQR) Apnea Hypopnea Index, Median (IQR) End-Tidal CO [2], Median (IQR) Lowest O [2] Desaturation, Median (IQR) Percent of the study < 90%, Median (IQR)
No Complications (n = 108)
Complications (n = 50)
N
%
N
%
6 22 4 8 2 13 22 91
7 15 4% 7% 2% 12% 20% 84%
3 17 10 13 10 16 16 41
3 5 20% 26% 20% 32% 32% 82%
4 9 77 24 29 65 417 21 16 52 74 2
4% 10% 85% 23 48 74 87 19 19 6 21 6
6 5 30 30 25 34 418 23 15 55 70 3
12% 10% 60% 24 26 97 82 24 27 10 32 15
Table 4 Characteristics associated with unplanned ICU.
Body Mass Index, Median (IQR) Comorbidities Gastrointestinal Flag Technology Dependent Flag Viral Infection Reflux Sleep Disordered Breathing Sleep Study Obstructive Sleep Apnea Mild Moderate Severe Respiratory Effort Related Arousals, Median (IQR) Apneas, Median (IQR) Hypoapneas, Median (IQR) Total Sleep Time, Minutes, Median (IQR) Respiratory Disturbance Index, Median (IQR) Apnea Hypopnea Index, Median (IQR) End-Tidal CO [2], Median (IQR) Lowest O [2] Desaturation, Median (IQR) Percent of the study < 90%, Median (IQR)
p value
0.0003 0.004 0.001 0.001 < 0.0001 0.003 0.11 0.72 0.11
0.67 0.42 0.11 0.62 0.52 0.38 0.11 0.14 0.25
Table 5 Complications in the unplanned PICU population.
No ICU (n = 156)
Unplanned ICU (n = 24)
p value
N
%
N
%
18
8
19
10
0.94
3 6
2% 4%
2 2
8% 8%
0.07 0.30
6 29 125 46
4% 19% 80% 29%
1 7 13 12
4% 29% 54% 50%
0.91 0.19 0.03 0.04 0.03
13 26 7 29
28% 57% 15% 18
3 3 6 32
13% 13% 25% 33
0.47
2 7 418
4 21 90
12 38 427
56 40 103
0.08 0.01 0.56
6
5
12
16
0.03
2
3
7
18
0.01
50
6
50
5
0.84
86
11
81
22
0.21
0
1
1
3
0.03
Unplanned ICU (n = 24)
Respiratory support Supplementary Oxygen Positive Pressure Complications Pulmonary Edema Atelectasis Pneumonia
N
%
21 10
88% 83%
4 7 4
17% 29% 17%
these patients could be due to pre-existing respiratory issues. Interestingly, we did not observe that more severe delineations of OSA and higher measurements on the sleep study were associated with complications. These results mirror those of del-Río et al., 2014, which supported that severe OSA does not indicate a higher rate of complications and thus higher levels of care [25]. Additionally, the findings that specific readings (AHI, RDI, etc) do not affect complication rates also validate prior research from Konstantinopoulou et. al. 2016 while refuting Thongyman et. al. 2014 [13,16]. Our study suggests that providers should be focused on planning for elevated levels of hospital care if the patient has a clinical history consistent with risk factors identified in this paper and not the severity of OSA as classified by the sleep study. This study is not without limitations. This is a single institution study, thus limiting the external validity of this investigation. Additionally, our hospital does not have a step-down unit from the PICU. The optimal study design to assess preoperative characteristics and the risk of complications following AT would be a prospective study where all patients underwent preoperative PSG. The absence of a PSG study in 52% of the sample population prevented an analysis of thresholds that would be appropriate for planned ICU stay postoperatively. A second limitation is that preoperative planning for PICU following AT is likely the result of individual provider decision making, which may vary across providers and also institutions. As a result, additional research is necessary to better understand the role of ICU referral postoperatively for AT and potential risks and benefits associated with ICU referral.
complications in the pediatric OSA population [22]. Yet, there is some analysis that suggests that perioperative viral infections do increase the rate of complications in pediatric patients undergoing surgery [23]. Additionally, a history of reflux has also been described before as a risk factor for complications following an AT, thus our findings validate this prior research [24]. Technological dependence is a term associated with the use of CPAP at home and its association with post-operative complications has not been well studied. The increased complication rate in 4
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5. Conclusion OSA severity as measured by PSG was not associated with a higher rate of complications in our study. Providers should plan for higher levels of hospital care for younger patients or those with a history of GI comorbidities, technology dependence, recent viral infection or reflux, as these were shown to be associated with higher rates of complications.
[11]
[12]
[13]
Disclosures [14]
C. Elmaraghy, Smith and Nephew: Consultant. Appendix A. Supplementary data
[15]
Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ijporl.2019.109736.
[16]
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