Outpatient tonsils question

[notryptase]

The 2019 AAO-HNFS guidelines for tonsillectomy state that pediatric patients with severe OSA should be admitted for post-op monitoring and more specifically that obese patients with BMI >95% should undergo sleep studies to check for severe OSA. However, per their own admission, compliance with these guidelines is quite low, roughly in the 40% range. There are a number of reasons for non-compliance including lack of sleep study availability, cost, disagreement with the validity of the guidelines, etc.

I wonder if anyone who works at a free standing ASC would be willing to share how they have navigated this issue with surgeons who choose not to obtain sleep studies for obese patients but still want to bring them to your center.

Thanks and sorry for the burner account, my group will immediately identify me given the time context should anyone read this forum 😁

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[Volatile]

We have a BMI cutoff for our ASC, it’s not usually an issue for kids but I suppose it would still apply. We don’t allow tonsils less than 3yo at our ASC. I can’t remember the cutoff for adenoids but I think it’s 2yo. At the end of the day the final say is ours and luckily our surgeons have been pleasant to work with and don’t push back. they understand we run pretty lean staffing wise, so one misbehaving kid in the pacu can really slow down the day which no one wants.

 

[notryptase]

We have a BMI cutoff for our ASC, it’s not usually an issue for kids but I suppose it would still apply. We don’t allow tonsils less than 3yo at our ASC. I can’t remember the cutoff for adenoids but I think it’s 2yo. At the end of the day the final say is ours and luckily our surgeons have been pleasant to work with and don’t push back. they understand we run pretty lean staffing wise, so one misbehaving kid in the pacu can really slow down the day which no one wants.

Interestingly the BMI cutoff has to be age specific because a BMI of 18 in a 4 year old would be obese.

Here’s the guidelines, forgot to include link earlier:

https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/aao-guidelines-tonsillectomy-2019.pdf

 

[crash2500]

We use bmi percentile for age. Nothing over 95th

 

[Iso4ane]

Thanks and sorry for the burner account, my group will immediately identify me given the time context should anyone read this forum 😁

So you could be me? Or I could be you. Ooo, the mystery.

 

[notryptase]

It is just a really weird problem. Like your own society says you should get sleep studies but a big chunk of surgeons are just saying no thanks. When common practice is not to follow society guidelines how do you argue they should be authoritative as a non-surgeon. Can’t imagine if the ASA had some practice guidelines on central line placement or something and everyone just said yeah whatever. I mean I’m being a little glib here but still.

 

[epidural man]

The 2019 AAO-HNFS guidelines for tonsillectomy state that pediatric patients with severe OSA should be admitted for post-op monitoring and more specifically that obese patients with BMI >95% should undergo sleep studies to check for severe OSA. However, per their own admission, compliance with these guidelines is quite low, roughly in the 40% range. There are a number of reasons for non-compliance including lack of sleep study availability, cost, disagreement with the validity of the guidelines, etc.

I wonder if anyone who works at a free standing ASC would be willing to share how they have navigated this issue with surgeons who choose not to obtain sleep studies for obese patients but still want to bring them to your center.

Thanks and sorry for the burner account, my group will immediately identify me given the time context should anyone read this forum 😁

Teach me…

If I have severe OSA from large masses in my throat, and I remove those masses, do I still have OSA? Why would I need monitoring after the problem is fixed?

 

[crash2500]

Teach me…

If I have severe OSA from large masses in my throat, and I remove those masses, do I still have OSA? Why would I need monitoring after the problem is fixed?

Studies show it's doesn't resolve immediately but can take up to a week. Most likely from surgical swelling and airway edema. I've seen uvulas that are literally sitting on a kids tongue in phase two recovery.

 

[PTPoeny]

Teach me…

If I have severe OSA from large masses in my throat, and I remove those masses, do I still have OSA? Why would I need monitoring after the problem is fixed?

Lots of kids sound worse and some kids desat just as much if not more the first night post-op. The swelling is real and very significant.

Though, I do have a selection bias because I only care for the ones the surgeon puts in the PICU post-op. Everywhere I have worked kids under 2 go to the PICU, so some age cut-off should be easy but I know that doesn't answer the main part of your question.

 

[IlDestriero]

Your group could determine if pediatric sleep studies are available in your area and if so require them when appropriate.
If they’re not available there’s not much you can do, other than opening a sleep center!
We have strict guidelines for what is allowed at the ASC. If you don’t meet them, then you don’t have surgery.

 

[notryptase]

Your group could determine if pediatric sleep studies are available in your area and if so require them when appropriate.
If they’re not available there’s not much you can do, other than opening a sleep center!
We have strict guidelines for what is allowed at the ASC. If you don’t meet them, then you don’t have surgery.

I’m beginning to wonder if opening a sleep center might not be extremely business savvy 😂

If sleep studies are not available should the kids not have surgery there? Ideally they would just go to an inpatient facility but sometimes the surgeon doesn’t have privileges at those places. I guess you could say then they shouldn’t be operating on those kids….

When the surgeons own the ASC or might as well own it, it’s a difficult position to argue from. Easier when the data or consensus is clear.

 

[The Duck Knows]

Teach me…

If I have severe OSA from large masses in my throat, and I remove those masses, do I still have OSA? Why would I need monitoring after the problem is fixed?

I always figured that I should be just as concerned with their increased sensitivity to opioids and their decreased hypercapnic drive. The physical obstruction might be gone, but the physiologic compensatory mechanisms take longer to resolve.

 

[anbuitachi]

i thought its any kid with severe osa gets monitored bed... even if not a tonsil case.

i recently had a 8 year old with severe OSA. AHI very high, forget what it is, came in for some non tonsil case. told surgeon this kid needs monitored bed after.

 

[anbuitachi]

It is just a really weird problem. Like your own society says you should get sleep studies but a big chunk of surgeons are just saying no thanks. When common practice is not to follow society guidelines how do you argue they should be authoritative as a non-surgeon. Can’t imagine if the ASA had some practice guidelines on central line placement or something and everyone just said yeah whatever. I mean I’m being a little glib here but still.

do they not want to get sleep studies because they dotn want to admit the kid for post op monitoring? its not severe sleep apnea if youve never been diagnosed

 

[notryptase]

i thought its any kid with severe osa gets monitored bed... even if not a tonsil case.

i recently had a 8 year old with severe OSA. AHI very high, forget what it is, came in for some non tonsil case. told surgeon this kid needs monitored bed after.

I don’t believe there are many studies showing risk for OSA alone. The T&A + OSA combo seems to be where the risk is concentrated. Despite that if a kid has severe enough OSA and is expected to require a fair bit of opioids/sedating meds post-op it would seem only prudent to admit no matter the case.

do they not want to get sleep studies because they dotn want to admit the kid for post op monitoring? its not severe sleep apnea if youve never been diagnosed

Ha! Maybe so… though I think sometimes they believe they can tell by history and exam whether the kid has severe osa even though it’s not a reliable screen. Then of course there’s the surgeons who don’t have admitting privileges anywhere and are seemingly loathe to give up cases.