Tonsillectomy and Mortality

Educational Objectives

The goal of this program is to improve the treatment of pediatric patients who have undergone tonsillectomy. After hearing and assimilating this program, the clinician will be better able to:

1. Manage the risks associated with the use of opioid analgesic drugs in children after tonsillectomy.

2. Minimize the risk for death related to bleeding, airway compromise, and fluid management in children
undergoing tonsillectomy.

Summary

Data from Sweden: national registries record every operation performed and every death; between 2004 and 2011, rate of deaths ≤1 mo after tonsillectomy and adenoidectomy (T&A) 2 in 82,000 (both due to obstruction of airway caused by bleeding); mortality rate for T&A in Sweden 1 in 41,000; speaker estimates US rate 3 times as high

Data from United States: rely on closed claims databases; unreliable because data dependent on filing of claims and reporting to data-collection agencies

Coté et al (2014): identified 73 deaths after tonsillectomy between 1990 and 2011 using data from survey combined with data from American Society of Anesthesiologists Closed Claims Project database; 42 deaths occurred in patients with obstructive sleep apnea (OSA); 31 in patients without OSA; 11 patients without OSA experienced apnea in perioperative period

Stevenson et al (2012): examined data from LexisNexis database from 1984 to 2010; found 72 deaths; postoperative bleeding principal cause of death; additional causes included anoxic events, problems with medications, and intraoperative events

Goldman et al (2013): conducted survey using electronic questionnaire sent to 9500 members of American Academy of Otolaryngology–Head and Neck Surgery; 550 responded (rate of response 6%); of 34 pediatric deaths reported, hemorrhage occurred in 7, and apnea in 22; 20 events occurred at home; estimated mortality rate 1 in 27,000; concluded medication-related events and unexplained deaths more prevalent than death related to bleeding; majority of events occurred at home

Opioids: common factor in many deaths related to T&A; Subramanyam et al (2014) reviewed closed claims after tonsillectomy; found 36 of 98 deaths related to anesthesia (16 definitely related to opioids); opioid-related deaths involved morphine, codeine, meperidine, or fentanyl patch; black box warning issued for use of codeine after tonsillectomy by US Food and Drug Administration because of variable metabolism to morphine; tramadol, oxycodone, and hydrocodone metabolized by same pathway

Alternative analgesic agents: Sadhasivam et al (2012) — suggested that use of genetic testing or alternative analgesic drugs to prevent opioid-related deaths in children undergoing surgery helpful; Kelly et al (2015) — randomized trial compared use of morphine with ibuprofen for analgesia after tonsillectomy; found rate of desaturation in group receiving morphine higher; analgesia, rate of bleeding, and interaction of drugs similar; Yellon et al (2014) — proposed schedule for analgesia using acetaminophen and ibuprofen; cautioned that use of ibuprofen requires well-hydrated child; Tweedie et al (2012) — reported use of acetaminophen and ibuprofen or diclofenac to minimize risks of respiratory suppression; Association of Paediatric Anaesthetists of Great Britain and Ireland — advocates use of acetaminophen and nonsteroidal analgesic drugs and avoidance of opioids

Dilemma: opioids effective in relief of pain, but risk for complications increased

Schymik et al (2015): conducted survey of 224 parents of children with and without OSA who underwent T&A; found ≈50% of parents would administer opioid to child with signs of oversedation regardless of status of OSA

Postoperative pain: in recent years, emphasis placed on elimination of all pain and distress in hospitalized children; Baugh (2014) suggested residual pain after tonsillectomy provides margin of safety by stimulating respiration; controlling instead of eliminating pain recommended; administration of opioids in PACU requires careful monitoring and assessment before discharge; speaker recommends avoidance of opioids at home; acetaminophen plus ibuprofen effective and safer; dexamethasone beneficial; Hwang et al (2016) performed meta-analysis and found honey reduced pain and promoted healing after tonsillectomy

Postoperative bleeding: causes of death include missed diagnosis, inadequate treatment of hypovolemia, and problems associated with anesthesia; case reports suggest administration of ondansetron may mask bleeding through prevention of vomiting; intraoperative hazards of anesthesia include failure to recognize hypovolemia and difficulty establishing airway; bronchoscopy may be required; management requires 2 working sources of suction, 2 laryngoscopes, equipment for rigid bronchoscopy, and provider of rigid bronchoscopy

Anesthesia-related causes of death

Compromise of airway: no increase in risk with use of laryngeal mask airway documented; small percentage of cases require conversion to endotracheal tube

Reactions to drugs: majority associated with agents injected by surgeon

Inappropriate management of fluids: includes administration of incorrect fluids (deaths related to administration of hypotonic fluids reported); only isotonic fluids appropriate for perioperative use; discontinue use of intravenous catheter when patient able to take fluids by mouth

Readings

Baugh RF: Observation following tonsillectomy may be inadequate due to silent death. Otolaryngol Head Neck Surg 2014 Nov;151(5):709-13; Coté CJ et al: Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: Houston, we have a problem! Anesth Analg 2014 Jun;118(6):1276-83; Glover JA: The incidence of tonsillectomy in school children. 1938. Int J Epidemiol 2008 Feb;37(1):9-19; Goldman JL et al: Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention. Laryngoscope 2013 Oct;123(10):2544-53; Hwang SH et al: The efficacy of honey for ameliorating pain after tonsillectomy: a meta-analysis. Eur Arch Otorhinolaryngol 2016 Apr;273(4):811-8; Kelly LE et al: Morphine or ibuprofen for post-tonsillectomy analgesia: a randomized trial. Pediatrics 2015 Feb;135(2):307-13; Luk LJ et al: Implementation of a pediatric posttonsillectomy pain protocol in a large group practice. Otolaryngol Head Neck Surg 2016 Apr;154(4):720-4; Ostvoll E et al: Mortality after tonsil surgery, a population study, covering eight years and 82,527 operations in Sweden. Eur Arch Otorhinolaryngol 2015 Mar;272(3):737-43; Outpatient Surgery: Did early discharge cause child’s death after tonsillectomy? 2012. www.outpatientsurgery.net/surgical-services/tonsillectomy/did-early-discharge-cause-child-s-death-after-tonsillectomy — 05-04-12. Accessed September 25, 2017; Sadhasivam S et al: Preventing opioid-related deaths in children undergoing surgery. Pain Med 2012 Jul;13(7):982-3; author reply 4; Schymik FA et al: Parental analgesic knowledge and decision making for children with and without obstructive sleep apnea after tonsillectomy and adenoidectomy. Pain Manag Nurs 2015 Dec;16(6):881-9; Stevenson AN et al: Complications and legal outcomes of tonsillectomy malpractice claims. Laryngoscope 2012 Jan;122(1):71-4; Subramanyam R et al: Anesthesia- and opioids-related malpractice claims following tonsillectomy in USA: LexisNexis claims database 1984-2012. Paediatr Anaesth 2014 Apr;24(4):412-20; Tate N: Deaths from tonsillectomy. Lancet 1963 Nov 23;2(7317):1090-1; Tweedie DJ et al: Peri-operative complications after adenotonsillectomy in a UK pediatric tertiary referral centre. Int J Pediatr Otorhinolaryngol 2012 Jun;76(6):809-15; Yellon RF et al: What is the best non-codeine postadenotonsillectomy pain management for children? Laryngoscope 2014 Aug;124(8):1737-8.

Disclosures

For this program, members of the faculty and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Steward was recorded at the 55th Clinical Conference in Pediatric Anesthesiology, held February 10-12, 2017, in Anaheim, CA, and presented by the Pediatric Anesthesiology Foundation, Children’s Hospital Los Angeles. For information about upcoming CME opportunities from the Pediatric Anesthesiology Foundation, Children’s Hospital Los Angeles, please visit www.pediatric-anesthesiology-foundation.com. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT511401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.