"Detroit girl, 9, dies after routine tonsillectomy"

[Carbocation1]

Detroit girl, 9, dies after routine tonsillectomy
Joel Kurth , The Detroit NewsPublished 11:10 p.m. ET Jan. 5, 2017 | Updated 10 hours ago

http://www.detroitnews.com/story/ne...heartbreak-girl-dies-tonsil-surgery/96228636/

"The report includes several possible issues precipitating the death: an undetected irregular heartbeat such as Brugada syndrome that can cause sudden cardiac arrest; an airway obstruction; bad reaction to anesthesia; seizure; or overactive blood clotting."

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[leaverus]

who knows without more information. it was post-op tho after she'd been sent home so i'm thinking most likely is tonsillar bleed -> airway obstruction

 

[Man o War]

Horrible.
Didn't Northstar take over the anesthesia contract a couple years ago at DMC?

 

[partydoc]

The peds group was separate. Not sure if they still are

 

[sigrhoillusion]

Very hard to tell with just one side of the story. Would love to see the records from the OR and PACU.

If they are telling the truth about it taking 2 hours and needed to be put back to sleep and excessive bleeding, then I might have to question the hospital.

But all that could be "patient talk" where what they say is nothing like what really happened. were they actually doing surgery for 2 hours, or were they just running 2 hours behind? Did she have emergence delirium and they gave her a little propofol/ precedex to calm her down which the patents might consider "a second Anesthesia". Was she really cauterized? Or did she just cough some blood on a napkin? All should be in the records.

The girl also looks skinny but would also like to see what her pre-op PSG showed and her AHI if they even got one.

 

[epidural man]

Sounds like overdose to me.

Sleep Apnea = opioid sensitivity = death after anesthesia. so sad.

 

[sigrhoillusion]

I wouldn't be shocked by overddose due to sensitivity to opioids, but at the same time bleeding wouldn't shock me either, especially if there's any truth to the bleeding part of the story and the prolonged surgery.

 

[Mman]

the only thing that seems factual from that article that I can definitely say is wrong is that it states surgery end time at 2:23 and patient discharged at 3:05. 42 minutes in PACU is too fast. Also not sure what they mean when they state she "was put under anesthesia twice". Did they have to reintubate in OR for bleeding immediately postop? If so should've had a much longer PACU stay than she had.

 

[WholeLottaGame7]

the only thing that seems factual from that article that I can definitely say is wrong is that it states surgery end time at 2:23 and patient discharged at 3:05. 42 minutes in PACU is too fast. Also not sure what they mean when they state she "was put under anesthesia twice". Did they have to reintubate in OR for bleeding immediately postop? If so should've had a much longer PACU stay than she had.

Definitely a lot of info missing.

But also, it's not a routine tonsil until you're like 2 weeks out and nothing bad has happened. Until then tonsils are never routine.

 

[HalO'Thane]

Clearly a lot of info missing but it sounds like undiagnosed obstructive sleep apnea until proven otherwise. How many pediatric patients even get PSG's anymore, particularly if they don't have very good insurance? There are several aspects of being in academic medicine that are a pain but one thing I am very grateful for is the fact that our surgeons are very conservative about keeping patients postop who have even the slightest hint of trouble, even if it is for observation 6-8 hours. My guess is that it helps that most services have an army of residents and fellows that do a lot of the grunt work of admitting patients so it is usually not much work added for the attending surgeon. This is particularly true in ENT where situations like this seem to happen all the time.

 

[Mman]

Clearly a lot of info missing but it sounds like undiagnosed obstructive sleep apnea until proven otherwise.

What makes you think it was undiagnosed? From the article...

"Anyialah needed the surgery because she had sleep apnea. Medical records indicate she frequently had runny noses, sometimes slept through school and gasped for air in her sleep."

It was diagnosed. I mean that's why kids get their tonsils out. Almost every single kid I take care of for t&a has diagnosis of either OSA or "sleep disordered breathing" on the chart and they are mostly medicaid patients. She had obstructive sleep apnea so they took her tonsils and adenoids out to surgically correct it.

 

[aneftp]

I think they will get hosed in court. Need to settle quickly.

42 minutes in pacu after NON ROUTINE TONSILLECTOMY. That's the only objective evidence a jury needs to see.

Obviously they encounter more than usual bleeding and 2 hours for tonsillectomy IS NOT ROUTINE.

Things happen during surgery. We understand that. But the 42 min PACU time for non routine tonsillectomy recovery looks bad. Very bad.

 

[HalO'Thane]

What makes you think it was undiagnosed? From the article...

"Anyialah needed the surgery because she had sleep apnea. Medical records indicate she frequently had runny noses, sometimes slept through school and gasped for air in her sleep."

It was diagnosed. I mean that's why kids get their tonsils out. Almost every single kid I take care of for t&a has diagnosis of either OSA or "sleep disordered breathing" on the chart and they are mostly medicaid patients. She had obstructive sleep apnea so they took her tonsils and adenoids out to surgically correct it.

Good point. I guess what I should have said is that perhaps they underestimated the severity of her obstructive sleep apnea and perhaps she wasn't the best candidate to be discharged that day. There is, in my opinion, a huge difference between a child with big tonsils and SDB who just occasionally gasps and pauses a few times per night versus a kid who has had an actual PSG and an AHI score greater than 30. Those are two entirely different patients who need to be treated much differently in the intraoperative and postoperative setting.

 

[Carbocation1]

Who is liable in this case - anesthesiologist, surgeon, or both? Thanks.

 

[Mman]

Who is liable in this case - anesthesiologist, surgeon, or both? Thanks.

when something like this happens, everybody is getting dragged in. Surgeon for not admitting patient and/or whatever surgical complication may have occurred, anesthesiologist for discharging patient from PACU, hospital system for whatever system issues contributed to it.

 

[Hoya11]

Detroit girl, 9, dies after routine tonsillectomy
Joel Kurth , The Detroit NewsPublished 11:10 p.m. ET Jan. 5, 2017 | Updated 10 hours ago

http://www.detroitnews.com/story/ne...heartbreak-girl-dies-tonsil-surgery/96228636/

"The report includes several possible issues precipitating the death: an undetected irregular heartbeat such as Brugada syndrome that can cause sudden cardiac arrest; an airway obstruction; bad reaction to anesthesia; seizure; or overactive blood clotting."

The Moms story of going to several different pharmacies trying to fill oxycodone in a snowstorm is suspicious. And she was just leaving the post op girl in the car alone while she was going in? Agree that it sounds like she wasnt awake enough to be discharged

 

[sigrhoillusion]

I also like how the article pretty much listed EVERY possible thing that could have killed the girl.

Bleeding, airway obstruction, heart problem, opioid overdose, anesthetic reaction, etc.

I'm going to go with ninja assassins. Or lupus. It's always lupus...

 

[sigrhoillusion]

Another thing I noticed from the article:

"She wasn’t doing well, drifting in and out of sleep and slumping deeper in her seat, Gambrell said.

So the family drove to get medicine. The doctor, Siegel, had written a prescription for oxycodone, a painkiller. They went to two nearby pharmacies. Neither would fill the prescription for the opioid that is often abused and can make drug stores the target of addicts."

So your child is not doing well, drifiting in and out of consciousness, and your thoughts are to pick her up some oxycodone...? The article might have left out the drug addict aspect cause I don't think it's right to paint that picture. That being said, I'm sure the discharge instructions mentioned something along the lines of calling/returning to hospital if certain things happened probably including bleeding, disordered breathing, unconsciousness, etc.

The thing that will get the hospital is if there is any truth to the prolonged procedure, continued bleeding, multiple anesthetics and short PACU stay. I don't work at a peds hospital but we do a ton of peds and I think our minimum PACU stay for peds cases (not sure age cutoff) is an hour, and many of the T+As stay overnight if they are for OSA and not chronic tonsillitis because of their risk of resp depression.

 

[aneftp]

Another thing I noticed from the article:

"She wasn’t doing well, drifting in and out of sleep and slumping deeper in her seat, Gambrell said.

So the family drove to get medicine. The doctor, Siegel, had written a prescription for oxycodone, a painkiller. They went to two nearby pharmacies. Neither would fill the prescription for the opioid that is often abused and can make drug stores the target of addicts."

So your child is not doing well, drifiting in and out of consciousness, and your thoughts are to pick her up some oxycodone...? The article might have left out the drug addict aspect cause I don't think it's right to paint that picture. That being said, I'm sure the discharge instructions mentioned something along the lines of calling/returning to hospital if certain things happened probably including bleeding, disordered breathing, unconsciousness, etc.

The thing that will get the hospital is if there is any truth to the prolonged procedure, continued bleeding, multiple anesthetics and short PACU stay. I don't work at a peds hospital but we do a ton of peds and I think our minimum PACU stay for peds cases (not sure age cutoff) is an hour, and many of the T+As stay overnight if they are for OSA and not chronic tonsillitis because of their risk of resp depression.

Kids with significant sleep apnea need postop monitoring overnight in the hospital. Everybody is screwed and will try to pin it on somebody else.

This case will never see the courtroom because you can't convince a regular person that a tonsil in an OSA pt is different from a "routine" tonsil.

This is why I never understand the civil jury system in the USA. A jury of one's peers in a medical malpractice case. While docs still "win" 70% of cases that go to trial. It's these bad cases like this where you are place in a catch-22 figuring where to settle or roll the dice and go to trial with a "jury of one's peer".

 

[epidural man]

The Moms story of going to several different pharmacies trying to fill oxycodone in a snowstorm is suspicious. And she was just leaving the post op girl in the car alone while she was going in? Agree that it sounds like she wasnt awake enough to be discharged

YES!

Why are you getting percocet when your kid is barely awake? And why are you leaving them alone in the car - especially when they are barely arousable?

And it wouldn't be bleeding - the parents would have said - "there was blood everywhere in the back seat!"

I think the parents have a huge amount of culpability in this case - and it is likely the physicians did everything right - maybe she met discharge criteria.

Although as mentioned with OSA - I think they are on the hook for that. Maybe we stop talking about this on a public forum. I would hate to give a prosecuting attorney fodder.

 

[Mman]

Kids with significant sleep apnea need postop monitoring overnight in the hospital.

FWIW we almost never keep those kids overnight. (vigorous knocking on wood) Besides, the obstructive tissue causing their sleep apnea is likely gone. Just don't give them a bunch of narcotics.

 

[Southpaw]

Don't remember last time we admitted kid overnight after T&A. Almost all are done for OSA. They don't need much, if any, narcotic.

Very sad, unfortunate case.

 

[Man o War]

YES!

Why are you getting percocet when your kid is barely awake? And why are you leaving them alone in the car - especially when they are barely arousable?

And it wouldn't be bleeding - the parents would have said - "there was blood everywhere in the back seat!"

I think the parents have a huge amount of culpability in this case - and it is likely the physicians did everything right - maybe she met discharge criteria.

Although as mentioned with OSA - I think they are on the hook for that. Maybe we stop talking about this on a public forum. I would hate to give a prosecuting attorney fodder.

Good point....there is so much missing information here it's hard to say what happened. Plus every "fact" presented was from the patient's family's perspective and we all know how that is.
I feel terrible for the family either way.

 

[aneftp]

Good point....there is so much missing information here it's hard to say what happened. Plus every "fact" presented was from the patient's family's perspective and we all know how that is.
I feel terrible for the family either way.

They have gone public for a reason. It's to put pressure on a quick multi million dollar settlement.

Lawyers want a quick payday rather than have this case drag out in court for 2-3 years. Wouldn't you? Get a 30-40% cut the 2-4 million dollar settlement. That's the magic number. That's an easy payday for them for the amount of time NOT SPENT on the case

Frankly the family is a pawn in the whole scheme of things. It was also be very dangerous to point fingers at the family for not doing enough. I hate to speculate on education level/income level of family and I won't. And it's a very trick tight rope defense malpractice lawyers have to maneuver when defending this case.

 

[IlDestriero]

Some people don't understand how to use pain medicine at all. Recently I was told by an Ortho surgeon about a family that had a moderately painful Ortho procedure and was given a generous supply of oxycodone to take as needed. They called several days later to complain that the kid couldn't go to school as he was too sedated from the pain meds and all he did was lay in bed all day. Upon further questioning, the kid complained of minimal pain yet was getting round the clock opiates, Tylenol, Motrin, etc. The parents thought they needed to use all of the opiate solution every 6 hours until empty!
I don't think we will ever know what happened to this child. It's a horrible outcome, but the mortality of a t&a is not zero, not even close. I believe it's 1:35k. Sometimes I think we do that many every year considering how much ENT we do every day. But having said that, over the last 10-15 years , we had a couple near misses and one death from a post op bleed that I'm aware of. I don't know the details of the death, other than it was in a patient that bled a week or so out and went to a local rural hospital a few hours away.
Tonsillectomies aren't benign, and I can't believe that some places aren't routinely admitting a significant subset of these patients, unless they're screened out. Managing opiates in the first 24 hours can be very challenging for patients with significant OSA getting these very painful surgeries, and the obstruction doesn't just immediately resolve with the t&a. If I have a bad vibe about some situation that's not going routinely in these cases, I arrange for an admission or watch them for a significant period of time. Maybe an additional 3-4 hours. If I'm at an ASC, I would just transfer them. I'd rather fill out some paperwork, get some emails from risk management, etc. and be conservative than regret my decision for the rest of my life.


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Il Destriero

 

[deleted59964]

Tragic case. Could be lots of causes - rather than speculate, I wonder what you all think of the way we do things in my part of the world.

Our usual practice all the way over here is ...

All tonsillectomies stay overnight (this may change for cost reasons soon)
If for osa they get apnea monitoring over night.

Anaesthetic
Premed - rarely. Midazolam mostly 0.5 mg/kg oral, or dexmedetomidine if osa
oral rae, paracetamol, fentanyl approx 2/kg, tramadol 2/kg load, dexamethasone, sometimes clonidine

Analgesia while in hospital
Paracetamol, ibuprofen, tramadol prn, and oxycodone 0.1-0.2mg/kg per dose 3-4 hourly prn (limit to 0.1 mg/kg if for osa)

Discharge meds
Paracetamol, ibuprofen, tramadol

How does that compare ?

 

[WholeLottaGame7]

Tragic case. Could be lots of causes - rather than speculate, I wonder what you all think of the way we do things in my part of the world.

Our usual practice all the way over here is ...

All tonsillectomies stay overnight (this may change for cost reasons soon)
If for osa they get apnea monitoring over night.

Anaesthetic
Premed - rarely. Midazolam mostly 0.5 mg/kg oral, or dexmedetomidine if osa
oral rae, paracetamol, fentanyl approx 2/kg, tramadol 2/kg load, dexamethasone, sometimes clonidine

Analgesia while in hospital
Paracetamol, ibuprofen, tramadol prn, and oxycodone 0.1-0.2mg/kg per dose 3-4 hourly prn (limit to 0.1 mg/kg if for osa)

Discharge meds
Paracetamol, ibuprofen, tramadol

How does that compare ?

Why are you admitting people overnight without monitoring them for apnea? Isn't that the point? Just trying to give them a nice comfy place to stay and some free food?

Otherwise that cocktail seems fine, if not a little heavy on the narcotic. We try to keep the fentanyl to 1-2mcg/kg, and I start oxycodone at 0.1mg/kg and will drop down to 0.05mg/kg if they have significant OSA. Also don't use a lot of tramadol. We do use precedex.

Not saying I never go higher on oxycodone, but if there was ever a time to "start low and go slow," it's with OSA tonsillectomies. I also don't titrate to the point that they're snockered, and I'm pretty explicit with families pre-op that I'd rather their kid be awake and screaming than asleep and having problems breathing.

 

[Planktonmd]

There is nothing mysterious here! A kid with sleep apnea who had prolonged general anesthesia because of complicated intra-op course, received additional opiates in PACU, and was discharged from PACU way too quickly before meeting discharge criteria.
The mother said that the kid was not responsive or following command at the time of discharge!
You can't blame the mother for being unable to diagnose hypopnea/apnea while driving around town trying to get the prescription filled.
The phenomenon of kids dying of opiates + residual sedatives/hypnotics after tonsilectomy is not a new thing, and it will continue to happen because people who lack common sense and clinical judgement will continue to be involved in the care of these unfortunate children.

 

[Planktonmd]

Why are you admitting people overnight without monitoring them for apnea? Isn't that the point? Just trying to give them a nice comfy place to stay and some free food?

Otherwise that cocktail seems fine, if not a little heavy on the narcotic. We try to keep the fentanyl to 1-2mcg/kg, and I start oxycodone at 0.1mg/kg and will drop down to 0.05mg/kg if they have significant OSA. Also don't use a lot of tramadol. We do use precedex.

Not saying I never go higher on oxycodone, but if there was ever a time to "start low and go slow," it's with OSA tonsillectomies. I also don't titrate to the point that they're snockered, and I'm pretty explicit with families pre-op that I'd rather their kid be awake and screaming than asleep and having problems breathing.

I think admitting kids to the hospital after airway surgery is excellent management, although the insurance companies might not like it, but if it saves one kid's life a year it is worth it.

 

[WholeLottaGame7]

I think admitting kids to the hospital after airway surgery is excellent management, although the insurance companies might not like it, but if it saves one kid's life a year it is worth it.

Yes, but only if you're monitoring them. What's the point of having a kid in hospital and checking q4 or q8 vitals if you're worried about apnea?

 

[dhb]

How does that compare ?

Well we don't give that much opiates 1 or 2 mg of morphine in PACU and we would never let a kid go home with a script of tramadol or percocet.

 

[Mman]

I think admitting kids to the hospital after airway surgery is excellent management, although the insurance companies might not like it, but if it saves one kid's life a year it is worth it.

Want to know who else doesn't like it? Hospitals. There aren't enough beds to admit all those kids. It's like adult sleep patients. If every adult OSA patient having surgery got admitted (or observed) overnight, you'd need a ton of extra hospital beds built.

 

[deleted59964]

Why are you admitting people overnight without monitoring them for apnea? Isn't that the point? Just trying to give them a nice comfy place to stay and some free food?

Otherwise that cocktail seems fine, if not a little heavy on the narcotic. We try to keep the fentanyl to 1-2mcg/kg, and I start oxycodone at 0.1mg/kg and will drop down to 0.05mg/kg if they have significant OSA. Also don't use a lot of tramadol. We do use precedex.

Not saying I never go higher on oxycodone, but if there was ever a time to "start low and go slow," it's with OSA tonsillectomies. I also don't titrate to the point that they're snockered, and I'm pretty explicit with families pre-op that I'd rather their kid be awake and screaming than asleep and having problems breathing.

The nurses still keep a close eye on the non apnea monitored kids.
Most in a 4 bed room, so a nurse is in there most of the time

Having them stay allows us to be a bit more generous with analgesia, and mostly the primary post tonsillectomy bleeds occur while the child is still in hospital with Iv access.

Agree it's a luxurious arrangement and there is increasing administrative pressure to change

 

[aneftp]

Want to know who else doesn't like it? Hospitals. There aren't enough beds to admit all those kids. It's like adult sleep patients. If every adult OSA patient having surgery got admitted (or observed) overnight, you'd need a ton of extra hospital beds built.

Agreed.

This is why healthcare peeps are in a no win situation when stuff like this happens especially pediatric patient.

Lawyers love to mention malpractice cases and premiums and payouts only total 1% of healthcare costs.

Yet there is really no mention of defensive medicine. It's estimated defensive medicine (ordering incessant stress tests, gi procedures etc) and even admitting every single pediatric patient with OSA overnight for monitoring. No knows the true cost. It sure ain't the 1% the lawyers quote with malpractice costs.

It's closer to 6-10% in my estimate.

 

[sigrhoillusion]

My usual for tonsils includes:

+/- po versed pre-op, (unless they are older and are OK with pre-op IV)

Mask induction for most (unless the IV)

Everyone gets 0.5mg/kg ketamine up front after getting glyco to dry them out. IV acetaminaphen during case.

Put them on PS ventilation and don't give them any narcs until they are back breathing, and that is rare before end of case. Only narc they get is fentanyl and I only give half of what I would give a non-OSA kid. 0.25-0.5mcg/kg at a time based on the OSA severity. And they rarely require the narcs intraop. I get so frustrated when I'm supervising and someone gives the fentanyl for HR. I find the kids who get the fentanyl solely because their HR went up but they weren't breathing yet end up taking forever to wake up. (And I wake them up, don't deep extubate)

Post-op they may require one dose of morphine and I only write again for a reduced dose which usually nips any pain in the butt. I rarely if ever bust out the Precedex for these cases.

One of my colleagues doesn't use ANY pain meds. Literally just gives propofol, tubes and wakes them up. Then gives pain medicine in PACU. Those are the kids I always hear going nuts in the PACU and the nurses hate it... haha.

In summary: IMHO ketamine is a great drug for T+As.

 

[Planktonmd]

Want to know who else doesn't like it? Hospitals. There aren't enough beds to admit all those kids. It's like adult sleep patients. If every adult OSA patient having surgery got admitted (or observed) overnight, you'd need a ton of extra hospital beds built.

Well, if there aren't enough beds then we should do less tonsillectomies not cut corners and risk patients lives.

 

[deleted9493]

Clearly a lot of info missing but it sounds like undiagnosed obstructive sleep apnea until proven otherwise. How many pediatric patients even get PSG's anymore, particularly if they don't have very good insurance? There are several aspects of being in academic medicine that are a pain but one thing I am very grateful for is the fact that our surgeons are very conservative about keeping patients postop who have even the slightest hint of trouble, even if it is for observation 6-8 hours. My guess is that it helps that most services have an army of residents and fellows that do a lot of the grunt work of admitting patients so it is usually not much work added for the attending surgeon. This is particularly true in ENT where situations like this seem to happen all the time.

Funny that you should say this because I have found private practice to be far more conservative with regard to postoperative admissions and preoperative sleep studies. That said, I am working at a children's hospital with a couple of outlying ambulatory centers and not practicing at those sites my exposure is limited generally to kids with reasons to be at a children's hospital.

 

[leaverus]

Everyone gets 0.5mg/kg ketamine up front after getting glyco to dry them out. IV acetaminaphen during case.

off topic but i dont give glyco to kids because ive always been under the impression it's too late by the time the kid is induced and iv started; i feel like a t&a would be half or nearly over by the time the antisialagogue effect kicks in. am i wrong?

 

[IlDestriero]

off topic but i dont give glyco to kids because ive always been under the impression it's too late by the time the kid is induced and iv started; i feel like a t&a would be half or nearly over by the time the antisialagogue effect kicks in. am i wrong?

True, but it would likely help post procedure in the PACU.


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Il Destriero

 

[Mman]

Well, if there aren't enough beds then we should do less tonsillectomies not cut corners and risk patients lives.

Isn't the surgery helping decrease morbidity? And what exactly is the mortality risk from sending a kid with OSA home post tonsillectomy? How does that risk compare to the kids chance of dying in a car crash that year?

 

[BigRedBeta]

The Moms story of going to several different pharmacies trying to fill oxycodone in a snowstorm is suspicious.

Oxycodone in liquid form is often NOT stocked by a good % of pharmacies. Depending on local prescribing habits of the children's hospital, it just doesn't make much sense for them. So it's not surprising, from this PICU attending's perspective, that they had trouble finding it.

Wonder if she'd actually had a sleep study done or not. An elevated AHI is an extremely reasonable reason to stay overnight - even going to the PICU if necessary. Without the formal study, who is to say that she wasn't normally having 10+ events an hour and that she was far higher risk than recognized.

ow many pediatric patients even get PSG's anymore, particularly if they don't have very good insurance?

My personal exp is that PSG frequency for kids is exploding. Maybe I wasn't paying attention before, and I haven't taken the time to look into the published data, but as ENT is moving away from doing tonsillectomies for "recurrent" strep throat, OSA is the new indication that keeps their numbers up.

 

[Mman]

Wonder if she'd actually had a sleep study done or not. An elevated AHI is an extremely reasonable reason to stay overnight - even going to the PICU if necessary. Without the formal study, who is to say that she wasn't normally having 10+ events an hour and that she was far higher risk than recognized.

We don't have the hospital beds, nurses, or physicians in this country to admit each of those kids overnight, let alone to a PICU bed.

 

[BigRedBeta]

We don't have the hospital beds, nurses, or physicians in this country to admit each of those kids overnight, let alone to a PICU bed.

Well it comes down to risk stratification. Not saying every kid needs an overnight stay, but AHI, developmental delay, obesity, age, and other underlying conditions are enough to give a good sense of who should stay and who shouldn't.

 

[Mman]

Well it comes down to risk stratification. Not saying every kid needs an overnight stay, but AHI, developmental delay, obesity, age, and other underlying conditions are enough to give a good sense of who should stay and who shouldn't.

I guess what I'm saying is it isn't enough to give a good sense of who should stay and who shouldn't, at least not in the real world. It's a big gray area. It is so commonly done as an outpatient even on fat kids with AHI > 10 that we don't have good data on who should get admitted and who shouldn't. I don't know what the "right" answer is. We occasionally admit someone, but it's pretty rare.

 

[Planktonmd]

Well it comes down to risk stratification. Not saying every kid needs an overnight stay, but AHI, developmental delay, obesity, age, and other underlying conditions are enough to give a good sense of who should stay and who shouldn't.

Another factor in determining who stays should be the parents degree of education and the home environment we are discharging the child to.

 

[Planktonmd]

Isn't the surgery helping decrease morbidity? And what exactly is the mortality risk from sending a kid with OSA home post tonsillectomy? How does that risk compare to the kids chance of dying in a car crash that year?

The surgery might help improve airway dynamics and sleep apnea as a long term goal, but acutely this is an airway surgery that produces swelling, inflammation and sometimes acute bleeding, then we add to that the respiratory depressant effects of sedatives and opiates, then we rush them out of PACU to be efficient and be able to squeeze in more cases, and we trust the child to parents with little education who we hope would recognize the signs of airway obstruction.
That's how these kids die!

 

[Mman]

The surgery might help improve airway dynamics and sleep apnea as a long term goal, but acutely this is an airway surgery that produces swelling, inflammation and sometimes acute bleeding, then we add to that the respiratory depressant effects of sedatives and opiates, then we rush them out of PACU to be efficient and be able to squeeze in more cases, and we trust the child to parents with little education who we hope would recognize the signs of airway obstruction.
That's how these kids die!

how many of them die? I don't know the actual number off the top of my head.

 

[Planktonmd]

how many of them die? I don't know the actual number off the top of my head.

I am personally aware of three cases over the past 10 years.
I am not sure what the actual numbers are.

 

[Mman]

I am personally aware of three cases over the past 10 years.
I am not sure what the actual numbers are.

I'm personally aware of none in that time frame and we do about 50 a week.

 

[IlDestriero]

My understanding is that the overall mortality is 1:35k. The guy in the article says 1:50k. I'm not sure what the mortality for ASC kids screened for significant comorbidity is. Probably much lower. The kids that usually end up in the PICU from my experience are the ones that look like they're going to end up in the PICU. Morbidly obese, dysmorphic, chronically ill appearing, former extreme preemies, etc. One kid was snoring awake while lying flat. Guess where he recovered.


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Il Destriero