Vidya T. Raman

Utility of screening questionnaire, obesity, neck circumference, and sleep polysomnography to predict sleep‐disordered breathing in children and adolescents

Polysomnography (PSG) remains the gold standard for diagnosing obstructive sleep apnea (OSA) and sleep‐disordered breathing in children. Yet, simple screening tools are needed as it is not feasible to perform PSG in all patients with possible OSA.

MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO

BACKGROUND AND OBJECTIVESnMRI is commonly used in the pediatric population and often requires sedation or general anesthesia to complete. This study used data from a pediatric accountable care organization (ACO) to investigate trends in MRI utilization and in the requirement for anesthesia to complete MRI examinations.nnnMETHODSnThe Partners for Kids (PFK) ACO claims database was queried for MRI examination encounters involving patients 0 to 18 years old from 2009 to 2014, with utilization expressed as encounters per 10,000 PFK members-months. Data were limited to 2011 to 2014 to ensure consistent billing of anesthesia services. Encounters were classified according to the presence of procedure codes for anesthesia or sedation.nnnRESULTSnMRI utilization was approximately constant over the study period at 11 to 12 encounters per 10,000 member-months. The need for anesthesia increased from 21% to 28% of encounters over 2011 to 2014. The latter increase was shared across 1- to 6-year-old, 7- to 12-year-old, and 12- to 18-year-old subgroups. In multivariable regression analysis of monthly utilization, increasing need for anesthesia could not be attributed to secular trends in patient demographics or types of examinations ordered. Paid cost data were available for outpatient MRIs, and MRIs with sedation accounted for an increasing share of these costs (from 22% in 2011 to 33% in 2014).nnnCONCLUSIONnThere was an increasing need for anesthesia services to complete MRI examinations in this pediatric population, resulting in increasing cost of MRI examinations and presenting a challenge to ACO cost containment.

Assessment of adenotonsillar size and caregiver-reported sleep symptoms among 3–6 year old children undergoing adenotonsillectomy

INTRODUCTIONnAdenotonsillectomy remains the accepted first-line treatment for obstructive sleep apnea syndrome (OSAS) in children. Tonsillar size may be especially relevant in risk stratification as it may impact symptoms of sleep disordered breathing (SDB). This study assesses correlations among subjective tonsillar grading, measured tonsillar size, and degree of adenoid obstruction in patients age 3-6 years with caregiver-reported symptoms.nnnMETHODSnChildren 3-6 years old undergoing adenotonsillectomy for OSAS were enrolled prospectively. The subjective tonsillar grade and degree of adenoid obstruction were recorded on physical examination by the otolaryngologist, and the objective tonsillar size was obtained from pathology reports. Spearmans rho was used to assess agreement among measures of tonsillar size and adenoid obstruction; and to correlate these measures with caregiver-reported SDB symptoms obtained from a pre-operative standardized questionnaire.nnnRESULTSnThe cohort included 103 boys and 97 girls of median age 4.8 (interquartile range [IQR]: 3.9, 5.9) years. Median subjective tonsillar grade was 3+ (IQR: 3+, 4+) while median tonsillar size was 2.7xa0cm (IQR: 2.5, 3) and median adenoid obstruction was 60% (IQR: 50%, 80%). The subjective tonsillar grade and measured tonsillar size were strongly correlated (ρxa0=xa00.31, pxa0<xa00.001), whereas adenoid obstruction was uncorrelated with either subjective tonsillar grade (ρxa0=xa00.01, pxa0=xa00.860) or measured size (ρxa0=xa0-0.05, pxa0=xa00.497). Tonsillar grade was positively correlated with 3 common caregiver-reported SDB symptoms (loud snoring, trouble breathing at night, and daytime sleepiness). Objective tonsillar size was positively correlated only with difficulty organizing tasks or activities, and adenoid obstruction was positively correlated only with stopping breathing during sleep.nnnCONCLUSIONnSubjective tonsillar grading by the otolaryngologist achieved better correlation than measured tonsillar size or degree of adenoid obstruction with caregiver-reported SDB symptoms in children 3-6 years of age undergoing adenotonsillectomy.

Effects of partial sleep deprivation on reaction time in anesthesiologists

Fatigue in anesthesiologists may have implications that extend beyond individual well‐being.

Discontinuous insurance coverage predicts prolonged hospital stay after pediatric adenotonsillectomy

BACKGROUNDnChanges in health insurance coverage have been implicated in limiting access to care and increasing morbidity risk. The consequences of insurance discontinuity for surgical outcomes are unclear. In this study, we explored whether recent insurance discontinuity was associated with prolonged inpatient hospitalization after adenotonsillectomy in children.nnnMATERIALS AND METHODSnWe retrospectively evaluated single-center data on children aged 2-18xa0y undergoing adenotonsillectomy with overnight stay in 2009-2014. Insurance coverage at surgery and over the preceding year was categorized as (1) continuous private, (2) continuous Medicaid, or (3) discontinuous (changes or gaps in coverage). The association between insurance discontinuity and prolonged hospitalization (≥2xa0d) was evaluated using multivariable logistic regression.nnnRESULTSnThe study included 1013 girls and 983 boys (aged 4.5xa0±xa02.9xa0y), of whom 205 (10%) required prolonged hospitalization. Insurance was continuous private for 749 patients (38%), continuous Medicaid for 1121 patients (56%), and discontinuous for 126 patients (6%). Prolonged stay was most common with discontinuous insurance (23/126, 18%), followed by continuous Medicaid (117/1,121, 10%), and continuous private insurance (65/749, 9%; Pxa0=xa00.004). In multivariable analysis, discontinuous insurance remained associated with prolonged hospital stay, compared with continuous private insurance (odds ratioxa0=xa01.88; 95% confidence interval: 1.06-3.33; Pxa0=xa00.031), and compared with continuous Medicaid (odds ratioxa0=xa01.86; 95% confidence interval: 1.09-3.19; Pxa0=xa00.023).nnnCONCLUSIONSnThis study demonstrates greater odds of prolonged hospitalization after adenotonsillectomy among children with recent gaps or changes in insurance coverage and illustrates the feasibility of studying influences of health insurance change on surgical outcomes using existing data in hospital electronic records.

Point-of-care testing for coagulation function: CoaguChek® XS System versus standard laboratory testing in pediatric patients with normal and abnormal coagulation function

PurposeIntraoperative abnormalities of coagulation function may occur for various reasons. In most scenarios, treatment is directed by laboratory parameters. Unfortunately, standard laboratory testing may take 1–2xa0h. The purpose of the current study was to evaluate a point-of-care testing device (CoaguChek® XS System) in pediatric patients.MethodsPatients ranging in age from 2 to 18xa0years, undergoing posterior spinal fusion (PSF) or cardiac surgery using cardiopulmonary bypass (CPB) were eligible for inclusion. After CPB and/or the surgical procedure, 2.8xa0ml of blood was obtained and simultaneously tested on both the standard laboratory apparatus and the CoaguChek® XS System.ResultsThe study cohort consisted of 100 patients (50 PSF and 50 cardiac cases) with 13 cases excluded, leaving 87 patients (49 PSF and 38 cardiac cases) for analysis. In PSF cases, reference laboratory international normalized ratio (INR) ranged from 0.98 to 1.77 while CoaguChek® XS INR ranged from 1.0 to 1.3. The correlation coefficient was 0.69. The results of the Bland–Altman analysis showed a bias of 0.09, precision of 0.1, and 95% limits of agreement ranging from −0.11 to 0.28. In cardiac cases, reference INR ranged from 1.68 to 14.19, while CoaguChek® XS INR ranged from 1.4 to 7.9. The correlation coefficient was 0.35. The results of the Bland–Altman analysis showed a bias of −1.8, precision of 2.1, and 95% limits of agreement ranging from −6.0 to 2.4.ConclusionsINR values obtained from CoaguChek® XS showed a moderate correlation with reference laboratory values within the normal range. However, in the presence of coagulopathy, the discrepancy was significantly greater, thereby making the CoaguChek® XS clinically unreliable.

Utility of screening questionnaire and polysomnography to predict postoperative outcomes in children

INTRODUCTIONnThe prevalence of pediatric obstructive sleep apnea (OSA) has increased concurrently with the increasing prevalence of obesity. We have previously validated a short questionnaire predicting the occurrence of OSA on polysomnography (PSG). This follow-up study assessed the utility of the questionnaire in predicting postoperative outcomes.nnnMETHODSnChildren undergoing surgery and completing a sleep study were prospectively screened for OSA using a short questionnaire. Procedures within 1 year of PSG were included in the analysis. Questionnaires were scored according to a cutoff previously deemed optimal for predicting OSA (apnea-hypopnea indexxa0≥xa05) on the sleep study. Postoperative outcomes included prolonged (>60xa0min) length of stay (LOS) in the post-anesthesia care unit (PACU) and oxygen requirement in the PACU.nnnRESULTSnThe study cohort included 185 patients (100/85 male/female) age 8xa0±xa04 years, undergoing adenotonsillectomy (nxa0=xa0109), other ear, nose, and throat (ENT) procedures (nxa0=xa018), or non-ENT procedures (nxa0=xa058). There were 45 patients with OSA documented by PSG and 122 patients identified as likely to have OSA according to questionnaire responses (89% sensitivity, 41% specificity). PACU LOS was prolonged in 55/181 (30%) cases and supplemental oxygen was used in the PACU in 29/181 (16%) cases. In separate multivariable models, supplemental oxygen use in the PACU was more common if a patient scored ≥2/6 points on the short questionnaire scale (ORxa0=xa05.0; 95% CI: 1.3, 19.9; pxa0=xa00.023) or if the patient was diagnosed with OSA on PSG (ORxa0=xa04.6; 95% CI: 1.6, 13.5; pxa0=xa00.005). Neither OSA on PSG nor questionnaire score ≥2/6 were associated with prolonged PACU stay.nnnCONCLUSIONnBoth OSA diagnosis based on the AHI and the questionnaire scale achieved comparable predictive value for the need for oxygen use in the PACU. The utility of the questionnaire in predicting rare adverse events (e.g., unplanned admission or rapid response team activation) remains to be determined. Our preliminary results support using a brief questionnaire scale for preoperative risk stratification among children with suspected OSA who have not had a formal sleep study.

Utilization of a postoperative adenotonsillectomy teaching video: A pilot study

BACKGROUNDnPediatric tonsillectomies are increasingly being performed as an outpatient procedure thereby increasing the parental role in post-operative pain management. However, it is unclear if parents receive adequate teaching regarding pain management. We introduced a video teaching tool and compared its efficacy alone and in combination with the standard verbal instruction.nnnMETHODSnA prospective study which randomized parents or caregivers of children undergoing tonsillectomyxa0±xa0adenoidectomy into three groups: 1) standard verbal post-operative instructions; 2) watching the video teaching tool along with standard verbal instructions or 3) video teaching tool only. Parents completed pre and post-instruction assessments of their knowledge of post-operative pain management with responses scored from 0 to 8. Telephone assessments were conducted within 48 post-operative hours with a subjective rating of the helpfulness of the video teaching tool.nnnRESULTSnThe study cohort included 99 patients and their families. The median pre-instruction score was 5 of 8 points (Interquartile range [IQR]: 4, 6) and this remained at 5 following instruction. (IQR:4, 6; pxa0=xa00.702 difference from baseline). Baseline scores did not vary across the groups (pxa0=xa00.156) and there was no increase in the knowledge score from pre to post-test across the three groups. Groups B and C rated the helpfulness of the video teaching tool with a median score of 4 of 5. (IQR: 4, 5).nnnCONCLUSIONSnA baseline deficit exists in parental understanding of post-operative pain management that did not statistically improve regardless of the form post-operative instruction used (verbal vs. video-based instruction). However, the high helpfulness scores in both video groups support the use of video instruction as an alternative to or to complement to verbal instruction. However, further identification of knowledge deficits is required for optimization of post-operative educational materials.

Insurance Coverage and Acute Care Revisits After Pediatric Ambulatory Tonsillectomy

We investigated whether patterns of health insurance coverage were associated with 30-day all-cause acute care revisits after ambulatory tonsillectomy at a free-standing quaternary-care pediatric hospital. Insurance patterns were classified from past encounters as continuous private, continuous Medicaid, Medicaid-to-private change, or private-to-Medicaid change. Among 478/675 boys/girls (age 9 ± 4 years) selected for analysis, 148 (13%) had 30-day revisits, whereas 96 (8%) changed from Medicaid to private insurance, and 99 (9%) changed from private insurance to Medicaid. Revisits were most common in the private-to-Medicaid group, compared with continuous private coverage (19% vs 10%; 95% CI of difference: 1%-18%; P = .007). The private-to-Medicaid group was most likely to be overweight, have symptoms of sleep disordered breathing, and have more past clinical encounters. In multivariable analysis, the greater risk of acute care revisits among children with private-to-Medicaid change in coverage was attributable to greater comorbidity burden and past health care utilization.

Pilot study comparing post-anesthesia care unit length of stay in moderately and severely obese children

ObjectiveObesity is a risk factor for surgical complications in adults and children. Differences in postsurgical outcomes according to severity of obesity [moderate: 95–98th age-gender-specific body mass index (BMI) percentile versus severe: ≥99th percentile] in children remain unclear. This study compared post-anesthesia care unit (PACU) stay and hospital admission between severely obese children and moderately obese children undergoing surgery.MethodsIn a retrospective review over a 6-month period, obese children, 2–18xa0years of age undergoing surgery were identified. Multivariate mixed-effects regression was used to compare PACU length of stay (LOS) need for opioid analgesia, and hospital admission between moderately and severely obese patients.ResultsThere were 1324 records selected for inclusion. PACU LOS did not significantly differ between moderately obese (50xa0±xa036xa0min) and severely obese patients (55xa0±xa038xa0min). There were no differences between moderately and severely obese patients in use of opioids in the PACU. Yet, severely obese patients were more likely to require inpatient admission than moderately obese patients.ConclusionsThe duration of PACU stay still averaged less than 1xa0h in our cohort, suggesting that the majority of these patients can be cared for safely in the outpatient setting. Future studies should focus on identifying the co-morbid conditions that may prolong postoperative PACU stay or result in unplanned hospital admission in moderately and severely obese patients. Our preliminary data suggest that these factors may include a younger age and the complexity or duration of the surgical procedure.