Postoperative Respiratory Events Research Articles

Postoperative residual curarisation in geriatric patients: a prospective, observational cohort study.

To evaluate the occurrence and potential risk factors of residual curarisation after surgery and the subsequent acute respiratory events in elderly patients. The prospective, cohort study was conducted at Ankara City Hospital from July to December 2021, and comprised data of geriatric patients undergoing elective surgery under general anaesthesia using moderate-acting nondepolarising muscle relaxants. Postoperative acute respiratory events in the post-anaesthesia care unit were subsequently noted. Data was analysed using SPSS 25. Of the 185 patients aged >65 years evaluated, 174(94%) were included; 88(50.6%) females and 86(49.4%) males. The incidence of residual curarisation was in 6(3.4%) patients. Postoperative residual curarisation was significantly associated with smooth recovery process (p<0.05). The recovery was associated with intraoperative bleeding, total dose of neuromuscular blocker, and the length of time from the last dose of neuromuscular blocker to antagonist administration (p<0.05). Postoperative critical respiratory events were more common in patients with postoperative residual curarisation (p< 0.001). The length of stay in post-anaesthesia care unit was 1.57 times longer in such patients (p=0.001). Postoperative residual curarisation increased length of hospital stay and respiratory complications.

Concordance between ARISCAT risk score and cardiopulmonary exercise test values in risk prediction of postoperative pulmonary complications of major abdominal surgeries in a tertiary cancer hospital: A cross‐sectional study

AbstractBackground and AimsPulmonary complications are common after surgery. They include vascular thrombosis, pneumonia, respiratory failure (RF), and pain‐related atelectasis. There are a number of models to predict the risk of postoperative respiratory events other than thrombosis. The aim of this study was to explore the correlation of assess respiratory risk in surgical patients in Catalonia (ARISCAT) scoring and cardiopulmonary exercise test (CPET) values in prediction of postoperative pulmonary complications (PPCs).MethodsCancer patients referred to a tertiary hospital for elective major abdominal surgeries were studied. Patients were evaluated by ARISCAT score and then CPET was performed to determine the risk of surgery based on maximal oxygen consumption (VO2) value. Patients were followed for RF occurrence up to 72 h after surgery. Finally, the concordance of ARISCAT score and CPET values was evaluated in risk prediction of PPCs.ResultsThe results showed that parameters VO2, ARISCAT score, and anaerobic threshold could predict postoperative RF. Of these parameters, ARISCAT showed the highest sensitivity (100%) and the highest specificity (90.5%) compared with other parameters (Youden's J statistic = 0.905). However, VO2 value showed the highest validity. The percentage of agreement between different subgroups (low, medium, and high) of both criteria (VO2 and ARISCAT) was equal to 81.45% (p &lt; 0.001) and the ϰ coefficient of the given weight was equal to 0.54 (p &lt; 0.001), indicating a good agreement between these two criteria.ConclusionARISCAT scoring showed high sensitivity and specificity to PPCs in cancer patients and good correlation with CPET value for prediction of PPCs. Therefore, it is a reliable and robust risk prediction tool in major abdominal surgeries on cancer patients.

Perioperative Hypoxemia and Postoperative Respiratory Events in Infants with Hypertrophic Pyloric Stenosis.

Normalization of metabolic alkalosis is an important pillar in the treatment of infantile hypertrophic pyloric stenosis (IHPS) because uncorrected metabolic alkalosis may lead to perioperative respiratory events. However, the evidence on the incidence of respiratory events is limited. We aimed to study the incidence of peroperative hypoxemia and postoperative respiratory events in infants undergoing pyloromyotomy and the potential role of metabolic alkalosis. We retrospectively reviewed all patients undergoing pyloromyotomy between 2007 and 2017. All infants received intravenous fluids preoperatively to correct metabolic abnormalities close to normal. We assessed the incidence of perioperative hypoxemia (defined as oxygen saturation [SpO2] < 90% for > 1min) and postoperative respiratory events. Additionally, the incidence of difficult intubations was evaluated. We performed a multivariate logistic regression analysis to evaluate the association between admission or preoperative serum pH values, bicarbonate or chloride, and peri- and postoperative hypoxemia or respiratory events. Of 406 included infants, 208 (51%) developed 1 or more episodes of hypoxemia during the perioperative period, of whom 130 (32%) experienced it during induction, 43 (11%) intraoperatively, and 112 (28%) during emergence. About 7.5% of the infants had a difficult intubation and 17 required more than 3 attempts by a pediatric anesthesiologist. Three patients developed respiratory insufficiency and 95 postoperative respiratory events were noticed. We did not find a clinically meaningful association between laboratory values reflecting metabolic alkalosis and respiratory events. IHPS frequently leads to peri- and postoperative hypoxemia or respiratory events and high incidence of difficult tracheal intubations. Preoperative pH, bicarbonate, and chloride were bad predictors of respiratory events.

Is a Difficult Airway Team Needed for Intubation at Removal of Mandibular Distraction Devices for Infants With Robin Sequence?

Difficult airway teams (DATs) are typically present to assist intubation at the initial mandibular distraction osteogenesis (MDO) operation for infants with Robin sequence (RS). In some institutions, the RS diagnosis triggers a "difficult airway" label for the infant, requiring DAT presence for future operations. By the time of distractor removal, however, breathing and airway anatomy are significantly improved. The objective of this study was to measure intubation difficulty and perioperative respiratory complications at MDO device removal as a proxy for the necessity for coordination with a DAT. This is a retrospective study including infants with RS from 2013 to 2021 who had MDO during infancy. Patients were excluded if they had a tracheostomy or MDO device failure. Predictor variables included demographic data, comorbidities, and apnea-hypopnea indices (AHIs) from pre- and immediate post-MDO polysomnograms. The primary outcome measures were number of intubation attempts, laryngoscopy grade, and perioperative respiratory events at the distractor removal operation. Descriptive statistics were computed including Fisher's exact, paired sample t-tests, and Wilcoxon rank tests, and P<.05 was considered statistically significant. The sample included 47 (60% male) patients with a mean age at MDO of 12.0±15.7weeks. Significant improvement in AHI was seen after MDO (pre-MDO: 26.8±18.4 events/hour; post-MDO 2.78±2.66 events/hour; P<.001). Average number of intubation attempts decreased from 2.09±1.36 to 1.30±0.75 (P<.001) and the most common post-MDO laryngoscopy grade was 1 (69%). There were no intraoperative and 2 (4%) minor postoperative respiratory events, both in patients with repaired congenital cardiac disease and not related to traumatic intubation. Neither difficult intubations nor perioperative respiratory events associated with intubation trauma were seen at distractor removal, suggesting that specialty airway assistance is not routinely needed after successful MDO. DAT presence should be determined on a case-by-case basis based on specific patient risk factors.

P140 Non-invasive Ventilation prior to Adenotonsillectomy

Abstract Introduction Prolonged wait times to ENT surgery, combined with the risk for post-operative respiratory events in children with severe OSA led to a clinical pathway of implementing CPAP therapy in children with severe OSA whilst on waiting lists for adenotonsillectomy. This study evaluated the impact of this pathway on the clinical care of these patients. Methods A retrospective review of medical records of patients under 18yrs of age diagnosed with OSA and initiated on CPAP whilst awaiting review by ENT / Adenotonsillectomy, between January 2019 and December 2020. Results 36 patients were identified, age 4.3 ± 3.2 years, 86% male, and 80.6% had comorbidities. 16 (44.4%) were overweight or obese, and for 8 (22.2%) obesity was the primary comorbidity. Mean delays: Sleep study to Referral = 4.5 ± 10.5 weeks, Referral to NIV initiation 5.6 ± 8.7 weeks, and NIV to ENT surgery 13.6 ± 13.6 weeks. Total delay from referral to the surgery was 19.6 ± 19.4 weeks. 31 (86%) children were initiated on therapy in hospital, and five (13.9%) patients were non-compliant with the therapy. Discussion Current delays to ENT surgery for children identified with OSA on sleep study average 5 months. Where OSA is sufficient to recommend ENT surgery, the majority (80%) of children tolerated CPAP therapy while they await surgery. We suggest that the benefits obtained are that therapy can be instituted more rapidly than surgery, and where children are able to use CPAP therapy it reduced the requirement for high-dependency or intensive care admission post-operatively.

Clinical Characteristics and Post-Operative Outcomes in Children with Very Severe Obstructive Sleep Apnea.

Available information on clinical characteristics and post-operative outcomes in children with very severe obstructive sleep apnea (OSA) is limited. Our study evaluates the clinical features and polysomnographic (PSG) variables that predict post-operative outcomes in children with an obstructive apneal hypopnea index (AHI) of more than 25 events/hr. In this study from a single tertiary care center, we performed a retrospective chart review of patients with an AHI > 25/hr, who underwent tonsillectomy and adenoidectomy (T&A) between January 2016 and September 2021. In total, 50 children were included in the study: 26.0% (13/50) of children experienced post-operative respiratory events and four children needed intubation and ventilator support. Compared with children without respiratory events, children requiring post-operative respiratory interventions were younger (4.4 ± 5.2 vs. 8.0 ± 5.2 years; p = 0.04), had higher pre-operative AHI (73.6 ± 27.4 vs. 44.8 ± 24.9; p < 0.01), lower oxygen nadirs (70.0 ± 13.0% vs. 83.0 ± 7.0%; p < 0.01), and had lower body metabolic index Z-scores (−0.51 ± 2.1 vs. 0.66 ± 1.5; p < 0.04). Moderate to severe residual OSA was identified in 70% (24/34) of children with available post-operative PSG; younger children had better PSG outcomes. Our study shows that post-operative respiratory events are frequent in children with very severe OSA, particularly with an AHI > 40/h, younger children (<2 years of age), lower oxygen saturation (SpO2), and poor nutritional status, necessitating close monitoring.

Adverse Respiratory Events After Pediatric Endoscopic Airway Surgeries.

Perioperative risk stratification of pediatric patients undergoing airway intervention remains crucial in identifying those at a higher risk of requiring postoperative intensive care unit (ICU) care. Here we determined the likelihood of and possible risk factors for developing perioperative adverse respiratory events (PAREs) requiring ICU care after various pediatric endoscopic airway surgeries (EASs). We conducted a retrospective chart review of pediatric patients who were aged <18 years and underwent EAS between 2015 and 2021. Early postoperative adverse events within 24 h of surgery were recorded and analyzed. Overall, 99 patients who underwent EAS were included. The age at the time of the intervention ranged from 8 months to 18years. Fifty-eight patients, median age was 4.83 years, underwent papilloma debulking with no high likelihood of PARE in this patient subgroup (OR = 0.48; 0.16-1.44). Twenty-five patients, median age was 9.72years, underwent balloon dilation of laryngotracheal stenosis with no increase in the likelihood of PARE in this patient population (OR = 2.02; 0.65-6.28). Early postoperative respiratory events occurred in 16 patients (16.2%). Most of these events (75%) manifested within 4 h after surgery. In a univariate analysis, intervention at the level of the subglottis or 2 or more laryngeal subsites increased the risk of PARE (OR = 6.57; 1.11-12.52 and OR = 3.73; 1.93-22.34, respectively). In a multivariate analysis, only intervention in the subglottic area maintained its effect (OR = 6.84; 1.82-25.65). Respiratory adverse events following pediatric EAS are not uncommon, and the majority are encountered shortly after surgery. Intervention in the subglottic area was an independent predictor of PARE.

Risk Factors for Post-Tonsillectomy Respiratory Events in Children With Severe Obstructive Sleep Apnea.

To identify risk factors for postoperative respiratory events in pediatric patients with severe obstructive sleep apnea (OSA). Retrospective single-institution retrospective cohort study of pediatric patients with severe OSA who were admitted postoperatively after tonsillectomy. Patients who experienced respiratory events after surgery were identified and differences between the respiratory event and no event groups were compared. There were 887 patients included in this study. 14.8% (n= 131) experienced a documented respiratory event. The following risk factors were found to be most significant: %sleep time with O2 < 90% (tb90) (95% CI=1.07-1.14, OR=1.10, p< 0.001), Black race (95% CI=1.53-3.58, OR=2.34, p< 0.001), primary neurologic co-morbidity (1.67-6.32, OR=3.27, p< 0.001), Down syndrome (1.25-5.94, OR=2.72, p =0.01), and age (0.84-0.94, OR=0.88, p< 0.001). Regression modeling demonstrated that the rate of respiratory events increased with tb90. Our results demonstrate that there are other potential risk factors outside of AHI and O2 nadir that are associated with respiratory events after tonsillectomy. Black race and prolonged desaturations during polysomnography (PSG) are independent risk factors. Measures of abnormal gas exchange on PSG may be better at identifying at risk patients. 4 Laryngoscope, 133:1251-1256, 2023.

Perioperative considerations for adult patients with obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a common, but often undiagnosed, sleep breathing disorder affecting approximately a third of adult surgical patients. OSA patients have increased sensitivity to anesthetic agents, sedatives, and opioid analgesics. Newer technologies (e.g., bedside capnography) have demonstrated that OSA patients have repetitive apneic spells, beginning in the immediate postoperative period and peaking in frequency during the first postoperative night. Compared to patients without OSA, OSA patients have double the risk for postoperative pulmonary as well as other complications, and OSA has been linked to critical postoperative respiratory events leading to anoxic brain injury or death. Patients with OSA who have respiratory depression during anesthesia recovery have been found to be high-risk for subsequent pulmonary complications. Gabapentinoids have been linked to respiratory depression in these patients. Surgical patients should be screened for OSA and patients with OSA should continue using positive airway pressure devices postoperatively. Use of shorter acting and less sedating agents and opioid sparing anesthetic techniques should be encouraged. In particular, OSA patients exhibiting signs of respiratory depression in postanesthesia recovery unit should receive enhancer respiratory monitoring following discharge to wards.

Postoperative Respiratory Events in Surgical Patients Exposed to Opioid Analgesic Shortages Compared to Fully Matched Patients Non-exposed to Shortages.

Shortages of opioid analgesics critically disrupt clinical practice and are detrimental to patient safety. There is a dearth of studies assessing the safety implications of drug shortages. We aimed to assess perioperative opioid analgesic use and related postoperative hypoxemia (oxygen saturation less than 90%) in surgical patients exposed to prescription opioid shortages compared to propensity score-matched patients non-exposed to opioid shortages. We conducted a retrospective study including adult patients who underwent elective surgery at The University of California San Francisco in the period August 2018-December 2019. We conducted a Gamma log-link generalized linear model to assess the effect of shortages on perioperative use of opioids and a weighted logistic regression to assess the likelihood of experiencing postoperative hypoxemia. There were 1119 patients exposed to opioid shortages and 2787 matched non-exposed patients. After full matching, patients exposed to shortages used a greater mean of morphine milligram equivalents/day (146.94; 95% confidence interval 123.96-174.16) than non-exposed patients (117.92; 95% confidence interval 100.48-138.38; p=0.0001). The estimated effect was a 1.25 (95% confidence interval 1.12-1.40; p=0.0001) times greater use of opioids in patients exposed to opioid shortages than non-exposed patients. After full matching, a greater proportion of patients exposed to shortages (19.06%) experienced hypoxemia compared with non-exposed patients (16.91%). In addition, a greater proportion of patients exposed to opioid shortages (1.20%) experienced hypoxemia reversed by intravenous naloxone administration compared with non-exposed patients (0.44%). Given the shortage prevalence, reliance on opioid medications, and related risk of respiratory depression, harm prevention measures remain critical to prevent postoperative complications that may compromise patients' safety.

Journal-related Activities and Other Special Activities at the 2021 American Society of Anesthesiologists Meeting

Journal-related Activities and Other Special Activities at the 2021 American Society of Anesthesiologists Meeting

This Month in Anesthesiology

This Month in Anesthesiology

The association between residual neuromuscular blockade (RNMB) and critical respiratory events: a prospective cohort study

BackgroundInadequate neuromuscular recovery might impair pulmonary function among adult patients who undergo general anaesthesia and might thus contribute to critical respiratory events in the post-anaesthesia care unit (PACU). The pilot study aims to understand the baseline incidence of residual neuromuscular blockade (RNMB) and postoperative critical respiratory events (CREs), which are described in a modified Murphy’s criteria in the PACU.MethodThis is a prospective cohort study from January to March 2017 from a tertiary hospital in Saudi Arabia with thirty adult patients over 18 years old scheduled for elective surgery under general anaesthesia with neuromuscular blocking drugs (NMBDs) who were enrolled in the study. The Mann-Whitney U tests, chi-square tests and independent-samples T tests were used. The train-of-four (TOF) ratios were measured upon arrival in the PACU by using acceleromyography with TOF-Scan. Subjects’ demographics, perioperative data and the occurrence of postoperative CREs in the PACU were recorded.ResultsTwenty-six (86.7%) patients out of thirty in the study have received rocuronium as NMBDs whilst neostigmine as a reversal drug with only 23 (76.7%). The incidence of RNMB (TOF ratio < 0.9) was in 16 patients (53.3%). The incidence of RNMB was significantly higher in female patients (p = 0.033), in patients who had not undergone quantitative neuromuscular monitoring before extubation (p = 0.046) and in patients with a shorter duration of surgery (p = 0.001). Postoperative CREs occurred in twenty patients (66.7%), and there were significantly more of these CREs among patients with RNMB (p = 0.001). In addition, a statistically significant difference was observed in the occurrence of CREs according to body mass index (p = 0.047).ConclusionThis research showed that RNMB is a significant contributing factor to the development of critical respiratory events during PACU stay. Therefore, routine quantitative neuromuscular monitoring is recommended to reduce the incidence of RNMB.

Frequency and Temporal Distribution of Postoperative Respiratory Depressive Events

The frequency and temporal distribution of postoperative respiratory depression (RD) events are not completely understood. This study determined the temporal distribution and frequency of RD episodes in postsurgical patients continuously monitored by bedside capnography and pulse oximetry. This was a post hoc study of a subset of postsurgical patients enrolled in The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial from 2 sites in the United States. These patients had undergone continuous bedside monitoring on general care wards. These data were adjudicated for potential RD episodes. The number of RD episodes per patient and the time of each RD episode were determined. The first RD episode experienced by a patient was classified as an "initial" episode, and the initial and all subsequent RD episodes experienced by a patient were classified as "all" episodes. A PRODIGY risk score was calculated. Data analyzed from 250 patients contained 2539 RD episodes in 155 (62.0%, 95% confidence interval, 55.7-68.0) patients with median 2 [0-8], range of 0-545 RD episodes per patient, with a PRODIGY risk score distribution of 100 (40.0%) low, 79 (31.6%) intermediate, 70 (28.0%) high (missing data from 1 patient). Median time to the initial RD episode was 8.8 [5.1-18.0] hours postoperatively. There was a peak occurrence of initial RD events between 14:00 and 20:00 on the day of surgery, and these were associated with a large number of subsequent events in the same timeframe. The peak time of all RD episodes occurred from 02:00 to 06:00. Patients with high PRODIGY risk scores had higher incidence and greater number of RD episodes per patient (P < .001, overall comparisons between groups for both incidence [χ2] and number of episodes [Kruskal-Wallis test]). Continuous monitoring of surgical patients demonstrates that RD episodes are common, and risk increases with higher PRODIGY scores. In this patient cohort, the rate of initial RD episodes peaked in the afternoon to early evening, while peak rate of all RD episodes occurred in early morning. Further, among patients with RD episodes, the number of episodes increased with higher PRODIGY scores.

Predictors of Occurrence and Timing of Post-Tonsillectomy Hemorrhage: A Case-Control Study.

To describe cases and timing of pediatric post-tonsillectomy hemorrhage (PTH), to evaluate predictors of PTH, and to determine the optimal amount of postoperative care unit (PACU) monitoring time. Using the Pediatric Health Information System (PHIS) database and electronic medical records, a matched case-control study from 2005 to 2015 was performed. A single, tertiary-care institution. Each case of PTH was matched with 1 to 4 controls for the following factors: age, sex, surgeon, and time of year. A total of 124 cases of PTH and 479 tonsillectomy controls were included. The rate and timing of postoperative bleeding were assessed, and matched pair analysis was performed using conditional logistic regression. Our institutional PTH rate of 1.9% (130 of 6949) included 124 patients; 15% (19) were primary (≤24 hours), with 50% (9) occurring within 5 hours. Twenty-one percent (4 of 19) of primary PTH patients received operative intervention. Eighty-five percent (105 of 124) of all cases were secondary PTH, and 47% (49) of those patients received operative intervention. Cold steel (OR 1.9, 95% CI 1.1-3.3) and Coblation (OR 1.9, 95% CI 1.2-3.1) techniques and tonsillectomy alone (OR 3.7, 95% CI 1.9-7.2) increased odds of PTH. Patients who developed PTH had 4 times the odds of having a preceding postoperative respiratory event than controls (OR 4.0, 95% CI 1.6-10.0). We conducted a rigorous case-control study for PTH, finding that PTH was associated with use of cold steel and Coblation techniques and with tonsillectomy alone. Patients with a postoperative respiratory event may be more likely to develop a PTH and should be counseled accordingly. A PACU monitoring time of 4 hours is sufficient for outpatient tonsillectomy.

Is Intensive Care Unit Admission Necessary After Removal of Mandibular Distraction Devices in Infants With Robin Sequence?

Intensive care unit (ICU) care is routinely required after the operation to initiate mandibular distraction osteogenesis (MDO) in infants with Robin sequence (RS). Many patients are also managed in the ICU after subsequent device removal. It is uncertain if ICU care, which is expensive and limited, is necessary after this second operation. The objective of this study was to evaluate the incidence of respiratory events following device removal. We hypothesized that respiratory events would be infrequent and non-ICU inpatient monitoring would be adequate. This is a retrospective study of patients with RS from 2013 to 2018. Patients were included if they had MDO and distractor removal during the first year of life. Patients were excluded if they had a tracheostomy or remained intubated after distractor removal. Postoperative respiratory events. Twenty-five (60% male) patients were included. Mean age and weight at distractor removal were 142 ± 79 days of life and 5.5 ± 1.1 kg. Mean apnea-hypopnea index after completion of distraction was 1.1 ± 1.5 events/hour. Two (8%) patients experienced postoperative respiratory events that required intervention. In 1 (4% of sample) of these, the event was deemed to have benefited from ICU-level care. Two variables were significantly associated with these events: congenital heart disease (P = .020) and concomitant procedure performed during the same operation (P = .020). Intensive care unit-level care is rarely needed after distractor removal in infants with RS. Intensive care unit admission should be considered in patients with congenital cardiac disease and when having multiple operations during the same anesthetic.

Respiratory depression in the post-anesthesia care unit: Mayo Clinic experience.

The anesthesia recovery is a complex physiologic process as systems recover from the effects of surgery and anesthesia. Inadequate recovery of respiratory physiology can lead to severe hypoxemia-induced end-organ damage and even death. Emerging evidence suggests that signs of respiratory depression during early anesthesia recovery may portend increased risk for future severe adverse events. This article briefly reviews the Mayo Clinic research experience and advances in clinical practice. From the implementation of a step-down model of discharge criteria in the post-anesthesia care unit (PACU), consisting of PACU nurses monitoring patients in predetermined periods for signs of respiratory depression, and delaying PACU discharge for patients who exhibit signs of respiratory depression, and early intervention in high-risk patients. Subsequent studies found that even a single episode of respiratory depression in the PACU was strongly associated with subsequent respiratory complications. Further, patient baseline characteristics found to be associated with respiratory depression included obstructive sleep apnea and low body weight, and surgical factors associated with increased risk included the use of preoperative sustained-release opioids, perioperative gabapentinoid use, higher intraoperative opioids, isoflurane as the volatile anesthetic, and longer surgical duration. Based in part of Mayo Clinic research, the FDA issued a warning in 2019 on gabapentinoids use and respiratory complications, increasing the recommended level of respiratory vigilance in patients using this medication. Understanding the complex nature of postoperative respiratory events requires a range of translational and clinical research and constant update of practice.

Effects of Sugammadex on Post-Operative Pulmonary Complications in Laparoscopic Gastrectomy: A Retrospective Cohort Study.

The use of sugammadex can reduce post-operative residual neuromuscular blockade, which is known to increase the risk of post-operative respiratory events. However, its effect on post-operative pulmonary complications is not obvious. This study was performed to evaluate the effects of sugammadex on post-operative pulmonary complications in patients undergoing laparoscopic gastrectomy between 2013 and 2017. We performed propensity score matching to correct for selection bias. Post-operative pulmonary complications (i.e., pneumonia, respiratory failure, pleural effusion, atelectasis, pneumothorax, and aspiration pneumonitis) were evaluated from the radiological and laboratory findings. We also evaluated admission to the intensive care unit after surgery, re-admission or an emergency room visit within 30 days after discharge, length of hospital stay, re-operation, and mortality within 90 days post-operatively as secondary outcomes. In the initial cohort of 3802 patients, 541 patients were excluded, and 1232 patients were analyzed after propensity score matching. In the matched cohort, pleural effusion was significantly reduced in the sugammadex group compared to the neostigmine group (neostigmine 23.4% vs. sugammadex 18%, p = 0.02). Other pulmonary complications and secondary outcomes were not significantly different between the groups. In comparison to neostigmine, the use of sugammadex was associated with a lower incidence of post-operative pleural effusion in laparoscopic gastrectomy.

Respiratory complications after adenotonsillectomy in high-risk children with obstructive sleep apnea: A retrospective cohort study.

Obstructive sleep apnea (OSA) occurs in 1%-4% of children; adenotonsillectomy is an effective treatment. Mortality/severe brain injury occurs among 0.6/10000 adenotonsillectomies; in children, 60% are secondary to airway/respiratory events. Earlier studies identified that children aged <2years, extremes of weight, with co-morbidities of craniofacial, neuromuscular, cardiac/respiratory disease, or severe OSA are at high risk for adverse post-operative respiratory events (AE). We aimed to: Firstly, investigate which risk factors were associated with AEs either in the post-anesthesia care unit (PACU), pediatric intensive care unit (PICU), or both in this population. Secondly, we investigated factors associated with post-operative PICU AE despite no event in the PACU in order to predict need of post-operative PICU after their PACU stay. Retrospective study of children admitted to the PICU after adenotonsillectomy between 08/2006-09/2015. Demographics, risk factors, and occurrence of AE (oxygen saturation <92, stridor, bronchospasm, pneumonia, pulmonary edema, re-intubation) were recorded. During the studied time period 4029 tonsil/adenoid procedures were performed in 3997 children. 179, admitted to the PICU post-operatively, met criteria for analysis. PICU AEs occurred in 59%: 44%-83% in any particular risk category. PACU AEs occurred in 42%. Of those with PACU events: 92% suffered AEs in the PICU; however, 35% of those without a PACU AE still suffered a PICU AE. Among high-risk children undergoing TA, absence of adverse events in PACU during a 2-hour observation period does not predict absence of subsequent AEs in the PICU.

Neonatal intensive care unit patients recovering in the post anesthesia care unit: An observational analysis of postextubation complications.

Neonatal patients are at higher risk in the perioperative period than older infants and children. Extubation as an early goal for noenatal intensive careunitpatients presenting for surgery is undergoing a renaissance period, and an exploration of adverse events following selection for extubation immediately after general anesthesia has not specifically been undertaken in this population. The objective of this study is to determine the adverse events most commonly encountered in neonatal intensive care unitpatients recovering from anesthesia in the post anesthesia care unit, quantify the risk of event occurrence, and identify risk factors that may increase the risk of postoperative adverse events. All neonatal intensive care unitpatients presenting to the operating room6/1/2014-5/31/2018 who recovered in thepost anesthesia care unit were included for analysis. Univariate analyses were conducted utilizing the Wilcoxon rank-sum test or Fisher exact test. Due to the low event rate, a small-sample generalized estimating equation model was created with a major event composite as the outcome and explanatory variables with P values<.1 on univariate analysis. Statistically significant continuous variables were then dichotomized based on Youden index. There were 707 operative cases in 607 patients. There were 81 total events recorded, and 64/81 were considered to be major events; all of which were respiratory. The risk of any postoperative event was 11.5%, major respiratory event requiring intervention by a nurse or provider was 9.1%, and reintubation was 0.8%. Birth weight<1.58kg (OR 3.71; 95% CI 2.11-6.53; P<.001) and postmenstrual age at surgery <41weeks (OR 3.20; 95% CI 1.54-6.63; P<.001) were strongly associated with an increased risk of a major postoperative respiratory event. The most important factors associated with major events in the post anesthesia care unitfollowing extubation of neonatal intensive care unitpatients were birth weight<1.58kg and postmenstrual age at surgery<41weeks. A patient with both features has a 7-fold increase in the odds of a major respiratory event in the post anesthesia care unit. Careful consideration of the postoperative ventilation and monitoring strategy must be given to patients with low birth weight (<1.58kg) or who are <41weeks postmenstrual age at the time of surgery.