Postoperative Apnea Research Articles

Incidence of postoperative delirium in patients with preoperative and postoperative Obstructive Sleep Apnea Syndrome. A Systematic Review of the literature.

Introduction:Clinical research has suggested that there might be a correlation between postoperative delirium (POD) and obstructive sleep apnea (OSA) syndrome. We aimed to assess the association between POD and OSA syndrome.Methods:The electronic database PubMed was searched using combinations of terms for “Delirium,'’ “Obstructive Sleep Apnea,'’ and “postoperative delirium.'’ Excluded were studies without comparison as well as cross-sectional studies, case series, and case reports. The search was conducted with restriction toward English or not to the date of publication.Results:We included four studies in this review. In two of those studies, an association was found between POD and OSA syndrome. Pooled analysis showed a significant correlation between the two.Conclusion:High-quality studies regarding the subject are rare and heterogeneous. However, despite the lack of high-quality studies regarding the subject, the ones that are performed well conclude that there is a correlation between POD and OSA syndrome. Future studies addressing the matter should be well set up controlled clinical trials to draw conclusions and be able to investigate modifiable factors that can be used in a standardized protocol.

ANI-моніторинг для оцінки ефективності варіантів анестезіологічного забезпечення пластичної хірургії носа

Метою роботи було вивчення ANI-моніторингу для оцінки періопераційної аналгезії і контролю балансу ноцицепції/антиноцицепції при різних варіантах анестезіологічного забезпечення пластичної хірургії носа. Матеріали та методи. Було обстежено 116 пацієнтів віком від 18 до 60 років з викривленням перегородки носа, яким проводилася септопластика в умовах комбінованої анестезії, що включала тотальну внутрішньовенну анестезію зі штучною вентиляцією легенів і місцевою анестезією лідокаїном. Усі пацієнти були розподілені на 4 групи: 1-ша група (n = 28) (контрольна) — зі стандартним комбінованим анестезіологічним забезпеченням; 2-га група (n = 31) — стандартне анестезіологічне забезпечення доповнювалося внутрішньовенною інфузією парацетамолу за 30 хвилин до початку операції в дозі 15 мг/кг (але не більше 1000 мг) одноразово; 3-тя група (n = 30) — проводилася інфузія дексмедетомідину, що починалася за 10 хвилин до індукції анестезії в дозі 0,7 мкг/кг/год і закінчувалася за 10 хвилин до завершення операції; 4-та група (n = 27) — проводилася інфузія дексмедетомідину, що починалася за 10 хвилин до індукції анестезії в дозі 0,7 мкг/кг/год і закінчувалася за 10 хвилин до завершення операції, в комбінації з внутрішньовенною інфузією парацетамолу за 30 хвилин до початку операції в дозі 15 мг/кг (але не більше 1000 мг) одноразово. Проводилася реєстрація АNI-індексу. Після операції реєструвалися рівень болю за візуально-аналоговою шкалою (ВАШ) і частота розвитку післяопераційної нудоти і блювання. Реєструвалася оцінка пацієнтами якості анестезії за допомогою шкали Iowa Satisfaction with Anesthesia Scale. Результати. У контрольній групі ANI-індекс на етапі інтубації, початку операції, на етапі найбільш травматичного моменту операції був нижче 50 одиниць, що, можливо, пов’язано з недостатнім рівнем аналгезії. У 2-й групі з використанням парацетамолу ANI-індекс в момент інтубації знижувався до 50 одиниць, але потім перебував у межах 50–70 одиниць. У 3-й групі з застосуванням дексмедетомідину ANI-індекс на етапі індукції анестезії та в момент пробудження пацієнта був вище 70 одиниць. У 4-й групі з комбінованим використанням дексмедетомідину і парацетамолу ANI-індекс на всіх етапах, крім початку операції, був вище 70 одиниць. При аналізі рівня післяопераційної аналгезії за ВАШ найбільш оптимальний рівень спостерігався у 2-й і 4-й групах пацієнтів. Частота розвитку післяопераційної нудоти і блювання була нижче в основних групах дослідження: 2-га група — 17 %, 3-тя група — 12 %, 4-та група — 14 % порівняно з пацієнтами контрольної групи — 20 %. При оцінці пацієнтами якості проведеної анестезії за Iowa Satisfaction with Anesthesia Scale кращі результати були отримані в 4-й групі пацієнтів, у якій 25 % оцінили якість анестезії як добру, а 75 % — як відмінну. Найгірші результати були отримані в 1-й групі пацієнтів, 30 % з яких оцінили якість анестезії як задовільну. Висновки. Використання АNI-індексу в анестезіологічній практиці дозволяє з високим ступенем специфічності в режимі онлайн мониторувати рівень сприйняття болю в інтра- і післяопераційному періоді і забезпечити поліпшення періопераційної аналгезії. Застосування парацетамолу і дексмедетомідину забезпечує більш надійну і повноцінну періопераційну аналгезію.

Adenotonsillectomy for the treatment of obstructive sleep apnoea in extreme paediatric obesity.

Adenotonsillectomy is a recognised treatment for paediatric obstructive sleep apnoea. Recent literature highlights the need to assess outcomes in the extremely obese subpopulation. This study reviewed the efficacy of adenotonsillectomy performed in patients with extreme obesity. A retrospective analysis of attendees at a tertiary paediatric obesity clinic was performed, identifying patients with a body mass index z-score equal to or more than three who had undergone adenotonsillectomy for obstructive sleep apnoea. Electronic patient records, including respiratory polygraphy, were analysed. Nine patients met the study criteria. All required nocturnal non-invasive ventilation pre-operatively. Mean age at referral was 6.9 years, and average age of non-invasive ventilation commencement was 7.8 years. Post-operatively, 8 patients (89 per cent) required non-invasive ventilation with evidence of post-operative obstructive sleep apnoea. In extreme obesity, adenotonsillectomy does not prevent the need for non-invasive ventilation. Management of this patient group requires treatment of obesity alongside potential surgical intervention. Poor efficacy in treating obstructive sleep apnoea may influence the decision to proceed with adenotonsillectomy.

Probable Change of Sleep Parameters after Resection and Reconstruction Surgeries in Patients with Oral Cavity or Oropharyngeal Cancers.

In patients of oral cavity or oropharyngeal cancers, resection of the tumor and reconstruction of the defect may reduce the framework, add a bulky flap, alter the tissue flexibility, and contribute to postoperative obstructive sleep apnea (OSA). Postoperative OSA and the potential consequences may decrease the survival rate and reduce patients' quality of life. It is unclear whether the surgery is associated with postoperative OSA. Here, we compared the polysomnographies (PSGs) before and after the surgery in 15 patients of oral cavity or oropharyngeal cancers (out of 68 patients of head and neck cancers) without a chemo- or radio-therapy. Each patient received the second PSG before the start of any indicated adjuvant therapy to prevent its interference. There were 14 men and 1 woman, with a mean age and a standard deviation (SD, same in the following) of 56.2 ± 12.8 years. There were 6 tongue cancers, 5 buccal cancers, 2 tonsil cancer, 1 lower gum cancer, and 1 trigone cancer. The results show that the surgery changed sleep parameters insignificantly in apnea-hypopnea index (AHI), mean oxyhemoglobin saturation of pulse oximetry (SpO2), minimum SpO2, mean desaturation, and desaturation index but increased mean heart rate in the patients with free flaps. These results hint that the effect of surgery on developing OSA was small in this sample, with a longer plate or a larger framework for a bulkier free flap. It needs future studies with a large sample size to generalize this first observation.

Coblation intra-capsular tonsillectomy: A prospective tertiary center trial

IntroductionThere is a growing interest in intra-capsular coblation tonsillectomy (ICT) for the treatment of obstructive sleep apnea (OSA) in children. Literature remains controversial regarding which intra-capsular tonsillectomy (IT) technique is most effective and with least morbidity. Therefore, the aims of this study are to objectively measure the post-operative morbidity and the effectiveness of the ICT technique. Materials and methods107 children undergoing ICT (with or without adenoidectomy) for upper airway obstruction due to tonsillar hypertrophy at a tertiary center university hospital were prospectively enrolled from March 2016 to March 2018. Efficacy of the surgery was assessed by a pre-and post-operative Obstructive Sleep Apnea score (OSA-18). Post-operative morbidity was measured based on the Parent's Post-operative Pain Measure questionnaire (PPPM), type and duration of administered pain medication, time before resuming a full diet and a normal activity, readmission for dehydration and post-operative bleeding incidence. ResultsAfter a mean follow-up of 21.6 months, OSA-18 mean total score was 78.77 (SD = 15.74) before ICT and 23.7 (SD = 9.25) after surgery, with a significant difference between pre-operative and post-operative scores (p < 0.001). Mean PPPM scores were low at all evaluation points (5.89, 2.42 and 0.83 at days 2, 5 and 10 respectively). Analgesic use was restricted to acetaminophen in nearly all children for a mean duration of 1.93 days. They resumed a normal diet after 2.42 days and a normal activity (including return to school) after 2.7 days. No hospital readmission nor post-operative hemorrhage were reported. ConclusionIntra-capsular tonsillectomy by coblation is an effective and safe procedure that provides rapid post-operative recovery with minimal analgesic requirements, thus deserving a wider application in treating upper airway obstruction due to tonsillar hypertrophy in children.

Comparison of laryngeal mask airway and endotracheal tube in preterm neonates receiving general anesthesia for inguinal hernia surgery: a retrospective study

BackgroundPreterm neonates are at higher risk of developing inguinal hernia, and have an increased risk of perioperative adverse events. Laryngeal mask airway (LMA) is claimed to be associated to decreasing perioperative respiratory complications compared to endotracheal tube (ETT) in infants under one year of age receiving minor surgery; thus, we conducted a retrospective survey in former preterm neonates below 5000 g to compare the respiratory complications between LMA and ETT in general anesthesia for inguinal hernia surgeries.MethodsThe inclusion criteria were: gestational age at birth under 37 weeks, body weight at surgery below 5000 g, and receiving scheduled inguinal hernia repair under general anesthesia with LMA or ETT. Infants who were dependent on mechanical ventilation preoperatively were excluded. The postoperative respiratory complications including delayed extubation, re-intubation, and apnea within postoperative 24 h were compared between groups.ResultsFrom July 2014 to December 2017, 72 neonates were enrolled into final analysis. There were 57 neonates managed with LMA, and only 15 neonates intubated with ETT during the study period. The gestational age at birth and post-menstrual age at surgery showed no significant difference between groups, although in the ETT group, the body weight at birth and at surgery were lower, and more infants had history of severe respiratory distress syndrome and had received oxygen therapy within two weeks prior to surgery. Surprisingly, none one of the infants developed delayed extubation, re-intubation, or postoperative apnea in the LMA group. In the ETT group, 40 percent of the neonates could not be successfully extubated in the operation theater.ConclusionIn preterm neonates, even in those younger than 52 weeks post-menstrual age who undergoing inguinal hernia repair in their early infancy, LMA appears feasible and safe as the airway device during general anesthesia in specific patient group. However, anesthesiologist might prefer ETT rather than LMA in some complex situation. In neonates with lower body weight at birth and at surgery, and with a history of severe RDS and oxygen-dependence, further prospective study is required.

Machine learning-based preoperative datamining can predict the therapeutic outcome of sleep surgery in OSA subjects

Increasing recognition of anatomical obstruction has resulted in a large variety of sleep surgeries to improve anatomic collapse of obstructive sleep apnea (OSA) and the prediction of whether sleep surgery will have successful outcome is very important. The aim of this study is to assess a machine learning-based clinical model that predict the success rate of sleep surgery in OSA subjects. The predicted success rate from machine learning and the predicted subjective surgical outcome from the physician were compared with the actual success rate in 163 male dominated-OSA subjects. Predicted success rate of sleep surgery from machine learning models based on sleep parameters and endoscopic findings of upper airway demonstrated higher accuracy than subjective predicted value of sleep surgeon. The gradient boosting model showed the best performance to predict the surgical success that is evaluated by pre- and post-operative polysomnography or home sleep apnea testing among the logistic regression and three machine learning models, and the accuracy of gradient boosting model (0.708) was significantly higher than logistic regression model (0.542). Our data demonstrate that the data mining-driven prediction such as gradient boosting exhibited higher accuracy for prediction of surgical outcome and we can provide accurate information on surgical outcomes before surgery to OSA subjects using machine learning models.

Recovery Characteristics in Neonates Following General Anesthesia: A Retrospective Chart Review.

IntroductionPreterm babies increasingly survive the neonatal period as a result of advanced care practices. Accordingly, anesthesiologists are likely to encounter these patients with greater frequency. Ex-premature infants and term neonates are known to have an increased risk of post-operative apneas following surgery and anaesthesia.MethodsFollowing approval from the Institutional Review Board, we performed a retrospective chart review of neonates 0-28 days of age who underwent general anaesthesia procedures over two years. Data collected included age days, sex, weight, gestational age, American Society of Anaesthesiologists (ASA) physical status, type of anaesthetic (general/regional/spinal), airway management, surgical procedure, intraoperative adverse events, duration of anaesthesia, medications administered, post-operative recovery location, the occurrence of apneic events, medical co-morbidities, duration of post anaesthesia care unit (PACU) admission, a requirement for neonatal intensive care unit (NICU) admission, and duration of hospital admission.ResultsA total of 239 charts were reviewed from January 1, 2015, to December 31, 2016. Ninety-five cases were excluded for required postoperative mechanical ventilation. For the remaining 144 cases, the mean age was 12.8 days, 65% male, 35% female, mean gestational age 38.6 weeks, mean post-menstrual age 40.5 weeks, mean ASA status 3.5, and mean weight 3.46 kg. Post-operative apnea was observed in two neonates (1.4%).Risk factors for postoperative apnea included lower gestational age at birth (median 37.5 vs. 39.1 weeks, p=0.26), lower post-menstrual age (median 38.5 vs. 41.0 weeks, p=0.18), and lower weight (median 2.8 vs. 3.5kg, p=0.27), respectively. ASA classification, preoperative anaemia, and known pathology were all significant risk factors for apnea (p<0.05). Significant factors from the bivariate analysis were preoperative anaemia, known pathology, age, duration of anaesthesia, weight, intraoperative fentanyl, and amount of neuromuscular blocker. Age and preoperative anaemia were significant predictors for recovery location. The odds of going to PACU vs NICU/PICU for post-operative recovery were 7.4 times greater for every two weeks greater age (95% CI=(2.80-19.31), p<0.001). ConclusionThis study corroborates previous findings of predictive risk factors for post-anaesthesia apnea in preterm and term neonates. Previously reported risk factors, including low gestational/post-menstrual age, lower weight, and intraoperative narcotic use, were likely contributors to one of the apneic events in our study. A larger sample size is warranted to confirm a valid predictive model. Standardized universal guidelines would be useful in eliminating local variation in PACU monitoring and discharge criteria in this vulnerable age group.

Reconstruction of mandibular defects involving the central segment with fibula osteoseptocutaneous free flap following ameloblastoma resection: Patient-reported outcomes

Mandibular defects involving the central segment are challenging. This study analyzes the impact of defect extent and reconstruction method on quality of life (QOL) and obstructive sleep apnea (OSA). Twenty-nine ameloblastoma patients received segmental mandibulectomy involving the C-segment and immediate fibula free flap reconstruction were recruited. Defects: (C: 2, LC: 11, LCL: 19). Mean defect length: 8.79 cm (± 2.34). Inset: Low-single-barrel (n: 19), with secondary distraction osteogenesis (n: 8/19), high-single-barrel (n: 7), double barrel (n: 3). Patients were surveyed using University of Washington Quality of Life (UW-QOL) and Berlin risk of postoperative sleep apnea questionnaires. Flap failure: None. Mean follow-up: 109.6 ± 92.8 months. Physical function 91.83 (± 14.92); social function 90.17 (± 17.19). No statistical difference between C, LC, and LCL was found, but C group which received low-single-barrel had the lowest score in appearance and chewing domains. In health-related QOL (HR-QOL) compared with 1 month before cancer, 69% reported best results. "Appearance" was the most important issue for the past 7 days, followed by "Chewing," prevailing in LC and C groups that predominately reconstructed by low-single-barrel. Berlin score: 7 patients (4 LCL, 3 LC≥8 cm) were at high risk for postoperative OSA. "Like-with-like" reconstruction with immediate endosteal dental implants yields the best results. Inset of fibula bone could affect outcomes, favoring double-barrel or single-high-barrel inset. Appearance and chewing remain the main concerns, largely, in those with low-single-barrel inset and no dental restoration. After long/extensive LCL and LC mandibulectomies, postoperative OSA warrants further investigation, and modification of resection/reconstruction techniques.

Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee.

Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia. The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality. Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.

Tongue-Based Procedures in Treating Refractory Obstructive Sleep Apnea in Down Syndrome Patients: A Systematic Review and Meta-Analysis

Objective: There is a high prevalence of obstructive sleep apnea (OSA) in pediatric and adult Down Syndrome (DS) patients that is refractory to adenotonsillectomy and continuous positive airway pressure. Newer treatment modalities have emerged with improved outcomes. The objective is to provide an updated systematic review and meta-analysis to analyze the clinical outcomes of OSA in pediatric and adult DS patients with hypoglossal nerve stimulation using Inspire, midline posterior glossectomy plus lingual tonsillectomy (MPG + LT), and combined genioglossus advancement plus radiofrequency (GGS + RF). Methods: A comprehensive literature search of PubMed and Google Scholar was performed followed by a meta-analysis. Studies with preoperative and post-operative Apnea Hypopnea Index (AHI) values were included with patients serving as their own control. Results: Across 5 studies, 56 patients were analyzed. The mean reduction in AHI was statistically significant before vs. after procedure ( P &lt; .001 for hypoglossal nerve stimulation using Inspire with a paired 2-tailed t-test and P = .031 for MPG + LT). Although individual patient AHI values were unavailable in the GGS + RF study, the standard difference in mean AHI was also significant for GGS + RF with P = .001. Device malfunction was the most common complication for Inspire while postoperative bleeding was observed for MPG + LT and nasopharyngeal obstruction and retropalatal collapse were observed for GGS + RF. Conclusion: This review reveals significant improvement in AHI with Inspire, MPG + LT, and GGS + RF for DS patients with refractory OSA. Further investigation is needed for comparison between these 3 therapies.

Development of the University Postoperative Obstructive Sleep Apnea Protocol (UPOP)

PurposeThe purpose of this project was to retrospectively analyze medical records to determine the relationship between surgical patients with obstructive sleep apnea (OSA) risk factors and the occurrence of a critical respiratory event (CRE) in the postanesthesia care unit (PACU), and to subsequently develop a protocol for postoperative care. Although OSA is prevalent among the surgical population, research has primarily focused on preoperative identification and tailored perioperative care with limited application of standardized postoperative OSA management. DesignSurgical charts were retrospectively reviewed between April 1, 2019 and June 31, 2019. Medical records were reviewed to identify surgical patients who had a diagnosis of OSA or two or more OSA risk factors. For patients who met initial inclusion, PACU charts were reviewed for the occurrence of a CRE while in PACU. Data analysis involved use of both Microsoft Excel 2011 and IBM SPSS Statistics Base, version 26. MethodsMedical records were reviewed to identify patients in PACU who had two or more documented OSA risk factors (body mass index >35, snoring, alcohol use, diabetes mellitus [DM], hypertension [HTN], or male) or a diagnosis of OSA (n = 1,361). This sample was further refined to determine the patients who had a CRE (oxygen saturation less than 92%; respiratory rate less than 10, Modified Aldrete Respiratory Score of 1 and/or lesser) while in the PACU (n = 200). FindingsThere was a statistically significant relationship between one CRE in the PACU and a pre-existing diagnosis of HTN, DM, snoring, alcohol use, and male gender (P < .001 for each variable). There was a statistically significant difference in body mass index between patients who experienced a CRE and those who did not (P = .004). HTN and DM (n = 16) were associated with the highest occurrence of a CRE. ConclusionsThe University Postoperative Obstructive Sleep Apnea Protocol was designed based on results and current evidence-based practice. Development of a postoperative OSA protocol will positively impact patient outcomes and may reduce health care expenditures. Next steps include protocol implementation and analysis.

The relationship between Chiari 1.5 malformation and sleep-related breathing disorders on polysomnography.

Chiari 1.5 malformation is a subgroup of the Chiari malformation in which tonsillar descent into the foramen magnum is accompanied by brainstem descent. No data exist on whether operative decompression in patients with Chiari 1.5 improves sleep-related breathing disorders (SRBDs) and whether there are radiological parameters predicting improvement. The authors performed a retrospective cohort study of consecutive pediatric patients with Chiari 1.5 malformation and SRBDs at the Alberta Children's Hospital. An SRBD was characterized using nocturnal polysomnography (PSG), specifically with the apnea-hypopnea index (AHI), the obstructive apnea index, and the central apnea index. Preoperative values for each of these indices were compared to those following surgical decompression. The authors also compared preoperative radiographic factors as predictors to both preoperative AHI and the change in AHI with surgery. Radiological factors included tonsillar and obex descent beneath the basion-opisthion line, the presence of syringomyelia, the frontooccipital horn ratio, the pB-C2 line, and the clivoaxial angle. Seven patients (5 males, 2 females) met inclusion criteria. One patient had two surgical decompressions, each with pre- and postoperative PSG studies (n = 8). The median age was 9 years. Before surgical decompression, 75% underwent tonsillectomy/adenoidectomy. The majority (87.5%) experienced snoring/witnessed apnea preoperatively. The median tonsillar and obex descent values were 21.3 mm and 11.2 mm, respectively. The median values for the pB-C2 line and clivoaxial angle were 5.4 mm (interquartile range [IQR] 4.5 mm, 6.8 mm) and 144° (IQR 139°, 167°), respectively. There was a statistically significant change from preoperative to postoperative AHI (19.7 vs 5.1, p = 0.015) and obstructive apnea index (4.5 vs 1.0, p = 0.01). There was no significant change in the central apnea index with surgery (0.9 vs 0.3, p = 0.12). No radiological factors were statistically significant in predicting preoperative AHI and change in AHI. This is the first series of pediatric patients with Chiari 1.5 with SRBDs who demonstrated a marked improvement in their PSG results postdecompression. Sleep apnea has a significant impact on learning and development in children, highlighting the urgency to recognize Chiari 1.5 as a more severe form of the Chiari I malformation.

A capnography and transcutaneous CO2 profile of bariatric patients during early postoperative period after opioid-sparing anesthesia.

Noninvasive monitoring of partial pressure of carbon dioxide can be accomplished indirectly with capnography (PETCO2) or with transcutaneous carbon dioxide monitoring (PTCCO2). The use of capnography has been shown to offer an advantage over pulse oximetry alone in the early detection of adverse respiratory events when supplemental oxygen is administered. Furthermore, capnography allows for the monitoring of various respiratory measures, including end-tidal carbon dioxide, respiratory rate, tidal volume, and changes in breathing patterns. Transcutaneous CO2 also closely approximates arterial CO2 values, but is not as easy to monitor for prolonged periods. The purpose of this study was to examine the usefulness of capnography and of transcutaneous carbon dioxide monitoring in patients recovering from obesity surgery at high risk of developing postoperative obstructive sleep apnea. In a prospective observational study, 64 bariatric surgery patients at risk of developing obstructive sleep apnea were monitored in the postanesthesia care unit (PACU) with either capnography alone (31 patients) or capnography plus transcutaneous carbon dioxide monitoring (33 additional patients) every 3-5 minutes for the duration of their recovery. Primary endpoints included end-tidal and transcutaneous carbon dioxide, peripheral oxygen saturation, respiratory rate, pain scores, and incidence of adverse respiratory events. Although no adverse pulmonary events were observed, capnography detected several patients who experienced short periods of respiratory apnea while maintaining pulse oximetry readings within normal limits. Transcutaneous values were slow to change and averaged 4.5 ± 5.5 mm Hg (P< .05) higher than corresponding end-tidal measurements. These results indicate the capabilities of both these noninvasive techniques for postoperative monitoring. Capnography acutely monitors changes in respiration, whereas transcutaneous monitoring more accurately reflects arterial CO2 levels.

Case Report: The Combined Spinal and Caudal (CSC) Anesthetic-Is this the New Ideal Anesthetic in a Formerly Preterm, High-Risk Infant with Chronic Lung Disease Undergoing Infraumbilical Surgery?

Postoperative apnea is a well-recognized clinical entity commonly occurring in formerly preterm, high-risk infants. Spinal anesthesia has been demonstrated to be an attractive alternative to general anesthesia as it is associated with reduction of early risk of postoperative apnea in infants, hence it has become a valuable anesthetic technique in infraumbilical and lower extremity procedures, including inguinal herniorrhaphy.

Augmentation of the posterior pharyngeal wall with autologous tragal cartilage for management of velopharyngeal valve insufficiency in adults

ObjectiveThe study aims to evaluate posterior pharyngeal wall augmentation using autologous tragal cartilage graft in adults with velopharyngeal valve insufficiency (VPI). MethodsThe study included 23 patients with VPI (grade I, II, III), with ages ranging from 19 to 45 years. Six patients had previously undergone simple palatoplasty for cleft palate, 8 patients had previously undergone adenotonsillectomy and 9 patients had previously undergone uvulopalatopharyngoplasty (UPPP). The procedure was done by implanting a piece of autologous tragal cartilage in the posterior pharyngeal wall. Patients were followed up for 24 months postoperatively. The evaluation of percent of speech intelligibility and grade of the closure of the velopharyngeal valve using video-nasopharyngoscopy was evaluated preoperatively and postoperatively. ResultsHighly statistically significant improvement in the grade of the closure of the velopharyngeal valve (P = 0.009) and percent of intelligibility (P = 0.001) was found after surgery. There were no postoperative airway obstruction or sleep apnea. ConclusionAugmentation of the posterior pharyngeal wall using tragal cartilage is an effective, safe and physiological surgical procedure in the management of VPI in adults who suffered hypernasality following palatal and oropharyngeal surgeries.

Inguinal Hernia in Preterm Infants: Optimal Timing of Herniorrhaphy to Prevent Preoperative Incarceration and Postoperative Apnea

Inguinal Hernia in Preterm Infants: Optimal Timing of Herniorrhaphy to Prevent Preoperative Incarceration and Postoperative Apnea

Comparison of Traditional Upper Airway Surgery and Upper Airway Stimulation for Obstructive Sleep Apnea

To compare patients with moderate-severe obstructive sleep apnea (OSA) undergoing traditional single and multilevel sleep surgery to those undergoing upper airway stimulation (UAS). Case control study comparing retrospective cohort of patients undergoing traditional sleep surgery to patients undergoing UAS enrolled in the ADHERE registry. 8 multinational academic medical centers. 233 patients undergoing prior single or multilevel traditional sleep surgery and meeting study inclusion criteria were compared to 465 patients from the ADHERE registry who underwent UAS. We compared preoperative and postoperative demographic, quality of life, and polysomnographic data. We also evaluated treatment response rates. The pre and postoperative apnea hypopnea index (AHI) was 33.5 and 15 in the traditional sleep surgery group and 32 and 10 in the UAS group. The postoperative AHI in the UAS group was significantly lower. The pre and postoperative Epworth sleepiness scores (ESS) were 12 and 6 in both the traditional sleep surgery and UAS groups. Subgroup analysis evaluated those patients undergoing single level palate and multilevel palate and tongue base traditional sleep surgeries. The UAS group had a significantly lower postoperive AHI than both traditional sleep surgery subgroups. The UAS group had a higher percentage of patients reaching surgical success, defined as a postoperative AHI <20 with a 50% reduction from preoperative severity. UAS offers significantly better control of AHI severity than traditional sleep surgery. Quality life improvements were similar between groups.

Management of obstructive sleep apnea in children with achondroplasia: Outcomes of surgical interventions

IntroductionChildren with achondroplasia are predisposed to obstructive sleep apnea (OSA), however little is known regarding surgical interventions and outcomes for this condition. The aim of this study was to evaluate the severity of OSA in children with achondroplasia and report outcomes of surgical interventions using polysomnography (PSG) parameters. MethodsRetrospective chart review of children with achondroplasia with documented OSA from 2002 to 2018 that had pre- and post-operative PSG results. Additional data extracted included age, gender, and type of surgical interventions. The primary outcome was change in postoperative obstructive apnea hypopnea index (OAHI). ResultsTwenty-two children with achondroplasia were identified that underwent formal PSG before and after confirmed OSA. The median age was 12 months (range 4 days–15.3 years, IQR 2 years) at time of initial PSG evaluation. The majority (72.7%) of patients had severe OSA with a median preoperative OAHI of 14.25 (IQR 9.4). The most common surgical intervention was adenotonsillectomy (n = 15). Multilevel surgical intervention was required in 9 (41.0%) patients. Post-operatively, 16 (72.7%) children experienced a reduction in OAHI, of which four (18.2%) had complete OSA resolution. OAHI scores increased in six (27.3%) children. Patients with the most severe OSA at baseline had greater improvements in post-operative OAHI (P < 0.01). Neither type nor number of surgical interventions was associated with improved outcomes (P = 0.51, P = 0.89 respectively). ConclusionsTreatment of OSA in children with achondroplasia remains challenging. Although reduction of OAHI is possible, caregivers should be counseled about the likelihood of persistent OSA and the potential for multilevel airway surgery.

Long-term neurodevelopment outcomes of regional vs general anesthesia for infants undergoing inguinal herniorrhaphy: A protocol for systematic review and meta-analysis.

Background:Whether regional anesthesia (RA) offers better long-term neurodevelopment outcomes compared to general anesthesia (GA) to infants undergoing inguinal herniorrhaphy is still under heated debate. The aim of this meta-analysis is to compare the long-term neurodevelopment impact of RA with GA on infants undergoing inguinal herniorrhaphy.Methods:A systematic search of MEDLINE, EMBASE, PubMed, the Cochrane Central Register of Controlled Trials, clinicaltrials.gov and controlledtrials.com will be performed. Published eligible randomized controlled trials (RCTs) or quasi-RCTs (including abstracts) through May 20, 2020 with language limit of English will be enrolled in the meta-analysis. Two reviewers will independently conduct the procedures of study selection, data extraction, methodological quality assessment, and risk of bias assessment. The primary outcome is long-term neurodevelopmental state (at 2- and 5-year follow-up) as reflected in the Bayley and the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) scales of infants development following surgeries. The secondary outcomes consist of satisfactory intraoperative infants immobility, duration of surgery, any anesthetic failure, the supplement of postoperative analgesia, postoperative apnea, and postoperative bradycardia. The pooled weighted mean differences (WMDs) or odds ratios (ORs) of each outcome measurement and relative 95% confident intervals (CIs) will be calculated. EndNote X8 (Clarivate Analytics) software will be applied to manage all citations. The Cochrane Review Manager version 5.3 software (RevMan 5.3) will be employed for statistical analysis.Discussion:This study will summarize scientific and practical evidence and provide evidence-based individualized decision-making guidance on anesthesia regimen for inguinal herniorrhaphy in infants.Registration:This protocol was registered with the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) on 17 June 2020 (registration number INPLASY202060064).