Tonsillectomy is one of the most common ambulatory operations performed in children. A frequent reason for performing tonsillectomy is to relieve airway obstruction in children with obstructive sleep apnea (OSA) and obesity. Is the procedure safe? Dr. Charles J. Coté, MD, Department of Anesthesia and Critical Care, The MassGeneral Hospital for Children, Boston, MA and colleagues surveyed members of the Society for Pediatric Anesthesia and queried the ASA Closed Claims Project to determine factors associated with adverse events or death in children undergoing tonsillectomy. The results of their study, now available online in the article “Death or Neurologic Injury After Tonsillectomy in Children with a Focus on Obstructive Sleep Apnea: Houston, We Have a Problem!,” is published in the June 2014 issue of Anesthesia & Analgesia.
From the survey, of those patients who experienced adverse events, the authors identified 92 undergoing tonsillectomy with adenoidectomy with adequate data, and another 19 patients from the closed claims project, or a total of 111 patients. These cases occurred over the last 20 years, though the majority occurred after 2003. Half of patients were 4-8 years of age and about a quarter were younger. Death was the most common adverse outcome and occurred in about ⅔ of the study population. Neurologic injury and prolonged hospitalization each occurred in about 10% of patients. In those with OSA, the event was associated with airway compromise. In children not considered at risk for OSA the event was associated with hemorrhage. If the event occurred after surgery, about half occurred within 24 hrs of the procedure. In a little less than half of patients the event occurred following discharge home. About half of those with postoperative events received opioids. Thirteen children suffered an event in the PACU, attributed mostly to opioid overdose or apnea. Two patients died in the PACU after monitors were removed. In both cases, the parent thought their child was sleeping. One child, though admitted overnight and discharged the next morning, died 48 hours after surgery.
Though uncommon, these events are solemn reminders that even common and routine procedures can be associated with disastrous complications. This chronicle of calamity reminds us that children at risk for OSA (a) must be treated conservatively and monitored closely, and (b), should only receive about half of the opioid dose because of increased sensitivity.