Major Respiratory Complications Research Articles

Polysomnography results versus clinical factors to predict post-operative respiratory complications following pediatric adenotonsillectomy

ObjectiveSystematically review the published literature comparing the presence of clinical features (age, BMI, co-morbidities, etc.) versus polysomnogram (PSG) results in the prediction of major post-operative respiratory complications following pediatric adenotonsillectomy (T/A) for the treatment of Obstructive Sleep Apnea Syndrome (OSAS). MethodsA systematic review of the PUBMED and EMBASE databases was performed to identify studies containing both clinical and PSG data predicting major post-operative respiratory complications following T/A. Inclusion criteria included English language and extractable data. Major respiratory complications were defined as events that required significant intervention (intubation, CPAP,etc.) and/or altered patient disposition. Random effect modeling was performed and study quality was assessed using the Newcastle-Ottawa Scale. ResultsTwenty-two studies met the inclusion criteria with a median sample size of 157 (range 26–1735) and published between 1992 and 2015. The most common study design was a case series. Most studies included multiple patients at high risk for respiratory complications (Syndromic, obese, etc.). The summary estimate of the major respiratory complication rate following T/A was only 5.8% (95% CI = 4.2–7.4%, p < 0.001, I2 = 99%). For studies with extractable data, 102 of 112 patients (91.1%) with a post-operative respiratory complication had a clearly identifiable clinical risk factor, the remainder (8.9%) had only moderate or severe OSAS on PSG and no other predictor. ConclusionThe major respiratory complication rate following pediatric T/A for OSAS is low even amongst series of high risk patients. The majority of the published literature report that readily identified clinical factors predict the large majority of post-operative respiratory complications following T/A.

Current Indications for Surgical Treatment of Primary Hyperparathyroidism in the Elderly

This study presents the results of surgery in the elderly for primary hyperparathyroidism (PHPT) from a single institution's experience. We retrospectively analyzed 898 cases of surgically treated PHPT, divided into two groups: 135 elderly patients (A) and 763 patients younger than 65 years (B). PHPT was symptomatic in 68.8 per cent patients in group A and in 81.6 per cent in group B. Unilateral temporary recurrent laryngeal nerve palsy was observed in 0.9 per cent in group A and 0.1 per cent in group B (P > 0.05). No cervical hematomas, mortality or major cardiovascular, neurological, respiratory or metabolic postoperative complications were registered. All the patients evaluated at one year had improvement in the quality of life, with increase of bone mineral density (BMD) in 85.6 per cent and 79.8 per cent of patients in groups A and B, with no significant differences between symptomatic and asymptomatic patients. Parathyroidectomy in elderly PHPT patients is safe, with rate of morbidity similar to what observed in younger individuals. Further investigations are recommended to confirm the role of surgery as an effective approach in elderly PHPT patients.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction.

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

Impacts of disease severity on postoperative complications in children with sleep‐disordered breathing

To investigate the effects of diseases severity on postoperative complications following adenotonsillectomy (T&A) in children with sleep-disordered breathing (SDB). Retrospective study. Children aged <18 years were enrolled and underwent T&A for treating SDB. Polysomnography was used to classify the disease severity: primary snoring (apnea-hypopnea index [AHI] <1), mild (AHI = 1-5), moderate (AHI = 5-10), and severe obstructive sleep apnea [OSA] (AHI ≥10). Postoperative bleeding was graded using a severity scale (level I, self-reported bleeding; level II, requiring inpatient admission; level III, requiring reoperation). Primary bleeding is defined as hemorrhage occurring within the initial 24 postoperative hours. Perioperative respiratory complications are defined as oxygen saturation of less than 90%, 92%, or 95% in the recovery room. Major respiratory complications include laryngospasm, pulmonary edema, pneumonia, and intubation at recovery stage. A total of 610 children were included, of whom 42 (6.9%), eight (1.3%), and six (1.0%) children showed levels I, II, and III postoperative bleeding, respectively. Only one child had primary bleeding. The incidence and timing of postoperative bleeding did not differ significantly for children with different OSA severities. The rate of perioperative respiratory complications ranged from 1.6% to 14.3% on the basis of their definitions. The Cochran-Armitage test supported the trend that perioperative respiratory complications increase with the AHI. Six children developed major respiratory complications, which were not significantly associated with OSA severity. Children with severe OSA have increased risks of perioperative respiratory complications. However, OSA severity does not influence major respiratory complications or postoperative bleeding in children. 4. Laryngoscope, 127:2646-2652, 2017.

Perioperative clopidogrel is associated with increased bleeding and blood transfusion at the time of lower extremity bypass

ObjectiveControversy persists surrounding the perceived bleeding risk associated with perioperative clopidogrel use in patients undergoing lower extremity bypass (LEB). The purpose of this study was to examine the LEB bleeding risk and clinical sequelae associated with clopidogrel. MethodsAll LEBs in the Vascular Quality Initiative (VQI) from 2008 to 2014 were studied. The exposure was perioperative clopidogrel. Primary outcomes were blood transfusion, estimated blood loss ≥500 mL, and reoperation for bleeding. Secondary outcomes included mean operative time, major cardiac events, respiratory complications, infectious complications, and in-hospital mortality. Univariate and multivariable analyses were used to analyze patients on the basis of clopidogrel use and its association with outcomes. Nonparametric test for trend and Mantel-Haenszel methods were used to analyze association of clopidogrel use with blood transfusion and secondary outcomes. ResultsAmong the LEB cohort (N = 9179), 28% (n = 2544) were taking clopidogrel and 72% (n = 6635) were not. Patients taking clopidogrel were more likely to have coronary disease, prior coronary intervention, abnormal findings on stress test, and aspirin use (P < .001 for all). Patients taking clopidogrel were more likely to receive blood transfusion (38% vs 24%; P < .001) and to have estimated blood loss ≥500 mL (21% vs 12%; P < .001). Reoperation for bleeding rates were similar (0.9% vs 1.1%; P = .9). Clopidogrel use was also associated with increased mean operative times (244 minutes vs 232 minutes; P < .001) as well as with cardiac complications (8.8% vs 6.5%; P = .001), respiratory complications (2.5% vs 1.6%; P = .007), and in-hospital mortality (1.3% vs 0.8%; P = .03). Multivariable analysis demonstrated that clopidogrel was associated with increased risk of 1- or 2-unit blood transfusion (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.1; P < .001) and >2-unit blood transfusion (OR, 2.0; 95% CI, 1.7-2.5; P < .001). Major cardiac events (OR, 1.2; 95% CI, 1.0-1.5; P = .05) and respiratory complications (OR, 1.4; 95% CI, 1.0-2.0; P = .03) were also independently associated with clopidogrel use. Weighted Mantel-Haenszel ORs controlling for blood transfusion amount revealed no remaining effect of clopidogrel on major cardiac events (OR, 1.1; P = .4) or respiratory complications (OR, 1.0; P = .8). ConclusionsPerioperative clopidogrel use in LEB surgery is associated with increased blood loss and blood transfusion. Associated clinical sequelae include increased cardiac and pulmonary complications. Accordingly, surgeons should consider discontinuation of perioperative clopidogrel when it is clinically appropriate unless it is strongly indicated at the time of LEB.

Modified radical mastectomy for intraductal breast carcinoma in a patient with active pulmonary tuberculosis under thoracic epidural anaesthesia

The incidence of breast carcinoma is on the rise in Asian countries like India and pulmonary tuberculosis is one of the most common infectious diseases encountered here. Although coexistence of active pulmonary tuberculosis and breast cancer in same patient is rare, it poses a huge challenge to the anaesthetist when patients having the above conditions concomitantly are posted for surgeries like mastectomy. Here we report the anaesthetic management of a case of breast carcinoma with active pulmonary tuberculosis managed successfully under thoracic epidural anaesthesia chosen to avoid major hemodynamic, respiratory and other complications like operation theatre pollution and drug interactions between anti tubercular and anticancer drugs and drugs used for general anesthesia.

Postoperative Complications After Coronary Artery Bypass Grafting in Patients With Chronic Obstructive Pulmonary Disease.

Coronary artery disease is common in patients with chronic obstructive pulmonary disease (COPD). Previous studies have shown that patients with COPD have a higher risk of mortality than those without COPD after coronary artery bypass grafting (CABG). However, most of the previous studies were small, single-center studies with limited case numbers (or their only focus was mortality). The aim of our study was to focus on readmission, acute myocardial infarction (AMI), acute respiratory failure (ARF), cerebrovascular accident, and venous thromboembolism rates after CABG in an Asian COPD population.We conducted a nationwide case–control study in Taiwan using the claims database of hospitalization between January 1, 2009 and December 31, 2013. Patients with COPD before CABG were defined as the case groups. Each case was propensity score-matched by age, sex, hypertension, diabetes, dyslipidemia, cardiovascular disease, cerebrovascular disease, and chronic kidney disease, with 2 controls selected from CABG patients without COPD. The outcomes of interest were mortality, wound infection, and the readmission rate over 30 days for the following diseases: AMI, pneumonia, ARF, cerebrovascular accident, and venous thromboembolism.There were 14,858 patients without COPD and 758 patients with COPD who underwent CABG. After propensity score matching, the 30-day mortality and 30-day readmission rates and AMI were higher in the non-COPD group. The incidences of pneumonia and ARF after CABG were higher in the COPD group.Chronic obstructive pulmonary disease does not necessarily lead to mortality, readmission, or AMI after CABG, and the major respiratory complications associated with CABG in patients with COPD were pneumonia and ARF.

A Large Retrospective Cohort of Patients Receiving Intravenous Olanzapine in the Emergency Department.

Olanzapine is an atypical antipsychotic with similar pharmacologic properties to droperidol. Due to the current droperidol shortage, the authors' clinical practice has been to substitute olanzapine for droperidol in many situations. At this time, olanzapine is U.S. Food and Drug Administration approved for oral and intramuscular (IM) use only, but due to its increased utility, intravenous (IV) olanzapine was recently approved for use in the study emergency department (ED). The authors sought to review the use and safety of IV olanzapine in the ED patient population. A retrospective review of consecutive patients receiving IV olanzapine between January 1, 2014, and July 1, 2014, was conducted. Data were collected via an electronic medical record review. The study was deemed exempt from informed consent by our institutional review board. A total of 713 patients received IV olanzapine during the study period. The median age was 38 years (range= 18 to 85 years), and 313 patients were male (43.9%). Primary indications for IV olanzapine administration included acute agitation (n=245, 34.4%), abdominal pain (n=165, 23.1%), headache (n=121, 17.0%), nausea and vomiting (n=107, 15.0%), pain (other; n=60, 8.4%), and unknown (n=15, 2.1%). IV dosing varied: 1.25 mg (n=20, 2.8%), 2.5 mg (n=185, 25.9%), 5 mg (n=507, 71.1%), and 10 mg (n=1, 0.1%). Forty-nine patients required a second dose of olanzapine (22 IV, 26 IM, one oral). The maximum total dose of olanzapine was 20 mg. Ninety-eight patients required a total of 146 doses of additional sedatives during their ED course. Other sedative medications included ketamine (n=17, 2.4%), haloperidol (n=48, 6.7%), and benzodiazepines (n=81, 11.4%). Hypoxia was noted in 74 patients (10.4%). Major respiratory complications, including airway stimulation or repositioning maneuvers and intubation, occurred in 15 patients (2.1%). After consensus review, one intubation was classified as "likely related" to olanzapine administration, and two were classified as "possibly related" to olanzapine. Akathisia likely occurred in four patients (0.6%), and no allergic reactions were identified. Electrocardiograms (ECGs) were performed in 322 patients. A total of 251 patients had an ECG performed before olanzapine administration (median QTc= 404 ms), and 88 patients had an ECG performed after olanzapine administration (median QTc= 415 ms). Acute alcohol and drug intoxication was common, 118 (16.5%) patients were positive for ethanol, and seven of 23 drug screens were positive for sympathomimetics. Thirty-four of 284 admissions (4.5%) were to intermediate or intensive care unit beds. No patients died while in the ED and no cases of sudden cardiac death were noted. In this large retrospective review, IV olanzapine appears to be a safe in the management of a variety of ED indications. Hypoxia was common, but serious airway compromise was rare.

Perioperative outcomes of elective inflow revascularization for lower extremity claudication in the American College of Surgeons National Surgical Quality Improvement Program database

BackgroundWe compared the early postoperative morbidity and mortality rates of contemporary aortofemoral bypass (AFB) and other inflow procedures for claudication. MethodsWe identified 1974 claudicants who underwent elective AFB (n = 566) or non-AFB (nonaortofemoral bypass [NAFB]; n = 1408) inflow reconstruction using the ACS-NSQIP database (2005 to 2012). Stent placement was not routinely captured. In propensity score–matched cohorts, we analyzed the association between type of inflow surgery and 30-day postoperative outcomes. ResultsAmong 824 propensity score–matched patients (AFB, n = 412; NAFB, n = 412), the 30-day mortality rate was 2.7% for AFB and .0% for NAFB (P = .0008). NAFB conferred significantly lower rates of major cardiac (.2% vs 2.4%, P = .0063), respiratory (.7% vs 10.9%, P < .0001), renal (.2% vs 1.9%, P = .0380), and septic (.5% vs 3.6%, P = .0014) complications, and fewer returns to the operating room (4.6% vs 9.9%, P = .0032), compared with AFB. Rates of major venous thrombosis, wound complications, peripheral nerve injury, and graft failure were similar between the groups. ConclusionsThis study reports a higher contemporary short-term complication rate with AFB compared to alternative inflow revascularization, against which future study of long-term durability may be weighed.

One more brick in the wall of protective ventilation in surgical patients.

On June 14, 2015, Ladha and colleagues published an article in the BMJ entitled "Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study", which investigated the effects of intraoperative protective ventilation on major postoperative respiratory complications. This study used data of over 69,265 patients in order to investigate patients over the age of 18 who underwent a non-cardiac surgical procedure between January 2007 and August 2014 and required general anesthesia with endotracheal intubation. The investigators found that intraoperative protective ventilation was associated with a decreased risk of postoperative respiratory complications. This study raises important questions about the ventilatory management of surgical patients.

Post-operative respiratory outcomes using a standard extubation protocol after elective gastrostomy tube placement in pediatric patients with spinal muscular atrophy type 1

Medical records of spinal muscular atrophy type 1 patients, who underwent elective laparoscopic Nissen fundoplication and gastrostomy tube insertion and extubation using a standardized clinical protocol, were retrospectively reviewed. All seven patients were successfully extubated using the protocol and discharged home on bi-level positive airway pressure without oxygen supplementation. There were no major respiratory complications in the post-operative period.

Risk factors for major complications in surgery for hypervascular spinal tumors: an analysis of 120 cases with adjuvant preoperative embolization.

To determine the frequency of major complications and identify related risk factors in surgery for hypervascular spinal tumors after preoperative selective arterial embolization. Patients with spinal tumors who underwent preoperative embolizations between January 2010 and March 2013 were retrospectively reviewed. Perioperative complications were classified as either major or minor. Preoperative and intraoperative factors were analyzed for any association with major complications using univariate and multivariate regression analysis. There were 120 embolizations with subsequent 120 spine operations that met the inclusion and exclusion criteria. Overall, 27.5% (33/120) experienced major complications and 11.7% (14/120) had at least two major complications. Respiratory complications were the most commonly seen with a rate of 10.8% (13/120). Multivariate regression analysis identified two risk factors for major complications: reoperation and higher score of surgical invasiveness index. Two risk factors were identified for two or more major complications: age≥65 years and higher score of surgical invasiveness index. Two risk factors were identified for major respiratory complications: thoracic surgery and higher score of surgical invasiveness index. However, embolization-related factors did not reach significance in the multiple regression model. Major complications in surgery for hypervascular spinal tumors after embolization are prevalent. Risk factors identified in this study are useful prognostic indicators when considering surgical treatment combined with embolization.

Pulmonary Complications in Patients with Brain Injury

The severity of brain injury is the main determinant of morbidity and mortality in neurocritical patients. However, the role of other associated extracranial complications should not be disregarded1 with pulmonary complications being among the most common ones (Figure 1).2 Major respiratory complications associated with injury to the Central Nervous System (CNS) are caused by airways dysfunction (inability to maintain passage due to neurologic depression or damage), respiratory muscles dysfunction (nerve injury) or intrinsic pulmonary disorders (infection, embolism, acute respiratory distress syndrome, etc.). The occurrence of such complications could potentially cause hypoxemia, which would secondarily aggravate the brain damage. This situation is known to account for up to 50% deaths resulting from brain injury and is considered to be an independent factor for mortality.1,3-8

Off-pump versus on-pump revascularization in females: a meta-analysis of observational studies

Coronary revascularization in female patients presents several challenges, including smaller target vessels and smaller conduits. Furthermore, late presentation and more co-morbidities than males may increase complication rates. The aim of this study was to assess whether off-pump coronary artery bypass (OPCAB) improves outcomes when compared to on-pump coronary artery bypass (ONCAB) in the female population. A systematic literature review identified six observational studies, incorporating 23313 patients (n=9596 OPCAB, 13717 ONCAB). These were meta-analyzed using random effects modeling. Heterogeneity, subgroup analysis, quality scoring and publication bias were assessed. The primary endpoints were 30-day mortality and major cardiac, respiratory and renal complications. Secondary endpoints were the number of grafts per patient. No statistically significant difference was observed in 30-day mortality between the OPCAB and ONCAB groups (4.8% vs. 0.7%; OR 0.96; 95% CI [0.41, 2.24], p=0.92). Significant inter-study heterogeneity was also present (I2=94%) and was not explained by study size or quality. Peri-operative myocardial infarction (OR 0.65; 95% CI [0.51, 0.84], p=0.0009) was significantly lower with OPCAB without significant heterogeneity; however, OPCAB did not significantly alter other morbidity outcomes. OPCAB was associated with a trend towards fewer grafts per patient than ONCAB. OPCAB is a safe alternative to ONCAB in the surgical revascularisation of female patients and may reduce post-operative myocardial infarction (MI). However, this does not translate into a reduction in 30-day mortality and OPCAB does not significantly improve other cardiovascular, renal or neurological outcomes. Late outcome data remains lacking and a well-structured, randomized trial is required to answer vital questions regarding the effect of OPCAB on women in the long-term.

Surgeon-administered Conscious Sedation and Local Anesthesia for Ambulatory Anorectal Surgery

Anorectal procedures are often performed in an outpatient setting using a variety of anesthetic techniques. One technique that has not been well studied is surgeon-administered conscious sedation along with local anesthetic. The purpose of this study was to evaluate the use of this technique with emphasis on safety, efficacy, and patient satisfaction. Chart review was performed on 133 consecutive patients who had anorectal procedures at an outpatient surgery center. Additionally, 65 patients were enrolled prospectively and completed a satisfaction survey. Inclusively, charts of 198 patients who underwent outpatient anorectal surgery under conscious sedation and local anesthesia under the direction of a colorectal surgeon from 2004 through 2008 were reviewed. Parameters related to patient and procedural characteristics, safety, efficacy, and satisfaction were evaluated. Surgeon-administered sedation consisted of combined fentanyl and midazolam in 90 per cent. Eighty per cent of procedures were performed in the prone position and 23 per cent were in combination with an endoscopic procedure. Eighty-two per cent were classified as American Society of Anesthesiologists Grade 1 or 2. Transient mild hypoxemia or hypotension occurred in 4 and 3 per cent of the patients, respectively. Mean operative time was 29 minutes with a mean stay in the postanesthesia care unit of 37 minutes. There were no early major cardiac or respiratory complications. Ninety-seven per cent of the patients surveyed reported a high degree of satisfaction. Surgeon-administered conscious sedation with local anesthesia was well tolerated for outpatient anorectal surgeries. Additional studies are needed to confirm the safety and efficacy of this technique.

An audit of the use of an opiate sparing, multimodal analgesic regime in children with Sleep Disordered Breathing/Obstructive Sleep Apnoea undergoing adenotonsillectomy

ObjectivesChildren with Sleep Disordered Breathing/Obstructive Sleep Apnoea have an increased incidence of respiratory complications following adenotonsillectomy. This may be partly related to an increase in sensitivity to opiates.An audit of such cases undergoing adenotonsillectomy was performed with the following aims:1.To measure and compare the incidence of postoperative respiratory complications following an already locally established opiate sparing, multimodal analgesic regime, with published reports.2.To measure local compliance with these guidelines.3.To consider which risk factor(s) best predicted the chances of a respiratory complication occurring, perhaps enabling a more efficient use of post operative resources in the future.4.To measure the incidence of postoperative haemorrhage and post operative nausea and vomiting. MethodsAll patients had Sleep Disordered Breathing/Obstructive Sleep Apnoea confirmed preoperatively by Overnight Oximtery Studies. Oximetry data was expressed as the lowest recorded saturation (SpO2Low %) and number of significant desaturations (see text) per hour (ODI4%). Case notes and oximetry studies were scrutinized for relevant perioperative anaesthetic and analgesic data, risk factors and complications. ResultsThe overall incidence of major and minor respiratory complications was low (1.6% and 27% respectively). Children who suffered any complication were more likely to be younger (p=0.0078), have a lower SpO2Low (p=0.004) and higher ODI4% (p=<0.0001). Multiple logistic regression showed ODI4% to be the best predictor of a potential respiratory complication (p=0.0032). An ODI4% of >8 may be the best cut off point in predicting complications (AUC=0.78, sensitivity=0.90) but it showed a poor specificity (0.57). Primary/secondary haemorrhage occurred in 0.4%/1.2% respectively and postoperative nausea and vomiting in 4.4%. ConclusionsA low dose opiate-based, multi modal analgesic regime appears to be effective and safe in children with Sleep Disordered Breathing/Obstructive Sleep Apnoea undergoing adenotonsillectomy.

Is day stay adenotonsillectomy safe in children with mild to moderate obstructive sleep apnoea? A retrospective review of 100 patients

ObjectiveThis study explored the perioperative course of 100 children with polysomnogram (PSG) proven mild to moderate OSA to evaluate if day stay adenotonsillectomy is safe. MethodsA retrospective chart review of patients who had undergone tonsillectomy with or without adenoidectomy following an overnight PSG at The Children's Hospital at Westmead Sleep Laboratory. 263 records were reviewed. Patients with apnoea hypopnea index (AHI) ≥1 and <15/h and/or a final sleep study report of mild to moderate OSA were included. Exclusion criteria were age <3 years, weight <10kg, or any significant co-morbidities or other surgery that would preclude day stay surgery. Demographic, PSG and post-operative data was analyzed. ResultsNo major respiratory complications occurred. No patient required an unplanned medical review for respiratory concerns, or admission to a high care facility. Eleven children left recovery with oxygen prescribed. One child had a desaturation to 88% in recovery, and one child had laryngospasm. The nine other children required oxygen to maintain saturation >90%.Supplemental oxygen was prescribed to 7 patients on the ward. Of these, three patients received supplemental oxygen beyond 6h. The other 97 patients had an uncomplicated post-operative course and would have been suitable for day-stay surgery. Increasing severity of OSA grade on pre-operative PSG was significantly associated with post-operative supplemental oxygen use (p=0.003; Cochrane-Armitage test for trend). ConclusionsChildren who are otherwise well with mild to moderate OSA have a sufficiently low risk of respiratory complications following adenotonsillectomy to permit day-stay surgery in the setting of appropriate facilities with careful post-operative monitoring for the first 6h to identify a small sub-group who require overnight observations.

Breast Reconstruction in the Morbidly Obese Patient

The authors assess the risk and safety profiles of both implant and autologous breast reconstructions in the morbidly obese population using the National Surgical Quality Improvement Program data sets. The authors reviewed the 2005 to 2010 National Surgical Quality Improvement Program databases, identifying encounters for Current Procedural Terminology codes including either implant-based reconstruction or autologous reconstruction. Patients were classified and compared based on World Health Organization obesity criteria. Complications were divided into three categories: major surgical complications, wound complications, and medical complications. During the study period, 15,937 breast reconstructions were identified. The incidence of obesity was 27.1 percent, with 4.0 percent defined as class III (morbidly) obese. Morbidly obese patients had significantly higher rates of almost all complications compared with nonobese patients, including major surgical complications (p < 0.001), medical complications (p < 0.001), respiratory complications (p = 0.015), venous thromboembolism (p = 0.001), and wound complications (p < 0.001). These patients also were more likely to require a return to the operating room both for any reason (p < 0.001) and specifically for prosthesis/flap failure (p < 0.001). Morbid obesity was found to be an independent predictor of wound complications (OR, 2.1; p < 0.001), surgical complications (OR, 1.6; p < 0.001), medical complications (OR, 1.6; p = 0.01), and return to the operating room (OR, 1.5; p < 0.001). There was no significant difference in the 30-day surgical complication rates between implant and autologous reconstructions in the morbidly obese (p = 0.23). Morbid obesity is associated with a significantly increased risk of perioperative complications that translates into progressive, higher rates of overall morbidity, regardless of reconstructive modality. Risk, II.

African American Ethnicity as a Risk Factor for Respiratory Complications Following Adenotonsillectomy

To evaluate whether African American ethnicity is a risk factor for major respiratory complications following adenotonsillectomy (T&A). Retrospective cohort study. A Canadian tertiary care center. PATIENTS Children aged 0 to 18 years who underwent T&A at our institution from 2002 to 2006 with planned or unplanned postoperative admissions. We evaluated the association between ethnicity and our main outcome measure, major perioperative respiratory complications of T&A. Parental report of ethnicity was available for 23% of our cohort. At our institution, African American children undergo a routine preoperative sickle cell test (TestSC). Data on TestSC were included for all children. We established that having a TestSC was an accurate proxy for African American ethnicity (sensitivity, 96%; specificity, 93%; positive predictive value, 77%; negative predictive value, 99%). Seventy-four of 594 children experienced major respiratory complications (12.5%). Compared with children who did not have major respiratory complications, those who did had a TestSC (P = .01), were 2 years or younger (P < .001) and had lower weight-for-age z scores (P = .04), moderate to severe obstructive sleep apnea (P = .003), and comorbidities (P < .001). When controlling for these variables in a multivariate analysis, children of African American ethnicity (TestSC used as a proxy) were at higher risk of having major perioperative respiratory complications (adjusted odds ratio, 1.82 [95% CI 1.05-3.14]) (P = .003). Children of African American ethnicity (TestSC used as a proxy) are nearly twice as likely to experience major respiratory complications related to T&A. Ethnicity may be an additional independent risk factor for clinicians to consider when planning for T&A.

Quantifying respiratory complications post-adenotonsillectomy in patients with normal or inconclusive overnight oximetry

BackgroundChildren with sleep-disordered breathing (SDB) are at risk of developing post-operative respiratory complications following adenotonsillectomy (T&A). Our goal was to describe and quantify these complications following T&A in children with clinical SDB but with a pre-operative overnight home oximetry score of “normal/inconclusive” (McGill Oximetry Score (MOS) of 1), and to determine whether these children could safely undergo surgery in peripheral hospitals or outpatient surgical centers.MethodsWe performed a retrospective chart review of patients 3 years and older who had T&A between 2003 and 2010 at 2 of our institution’s hospitals. To be included in the study, in addition to not having severe comorbidities, children had to have undergone an overnight home oximetry within 12 months of surgery that was normal or inconclusive (MOS of 1). This was defined as fewer than 3 episodes of oxygen desaturation below 90% and stable baseline saturation over 95%. Medical charts were reviewed for major and minor postoperative respiratory complications. The main outcome measure was post-T&A respiratory complications.ResultsOut of 2708 T&A patients, 231 met the inclusion criteria. No patient had a major postoperative respiratory complication requiring re-intubation or admission to the intensive care unit. Five patients (2.16%) had minor respiratory complications but only one required admission to the ward.ConclusionsAn overnight home oximetry that is “normal/inconclusive” (MOS of 1) can be used as a screening tool to identify patients with sleep-disordered breathing who can be safely sent to peripheral hospitals or outpatient surgical centers for T&A.