GA5-93
A multimodal approach to the post-operative analgesic management of a pediatric patient with severe obstructive sleep apnea undergoing a nephrectomy and adenotonsillectomy
Tunceroglu H, Austin T, Lam H, Rosenberg E
Emory University, Atlanta, GA, USA
Introduction: Patients with obstructive sleep apnea (OSA) undergoing major surgery pose many challenges for pediatric anesthesiologists. These patients are at increased risk for postoperative respiratory complications such as laryngospasm, apnea, pulmonary edema, and perioperative death (1). The increased analgesic requirement after major surgery may further complicate their postoperative care. A multimodal analgesic approach that includes regional blocks and non-opioid analgesics is particularly important in these complex children. We describe the successful pain management of a patient with a transplanted kidney and severe OSA undergoing a nephrectomy and adenotonsillectomy (T&A).
Case Description: A 3-year-old male status post kidney transplant and right nephrectomy presented for a left nephrectomy via mini laparotomy through a subcostal incision for nephroblastomatosis. In addition, he was scheduled for a T&A due to severe OSA (apnea hypopnea index of 10.2 and SpO2 nadir of 78.3%). Previously, the patient had an incident of upper airway obstruction during anesthetic induction that led to hypoxia and eventually bradycardia requiring the initiation of Pediatric Advance Life Support and a separate episode of cardiac arrest following extubation. Due to this history, recovery was planned for the PICU. To minimize perioperative opioid use while covering the incision, a high-volume caudal block was performed with 1.5cc/kg of 1/6% bupivacaine. 1mcg/kg of clonidine was added to increase block duration and provide sedation/analgesia for the T&A. The patient also received 30mg/kg of rectal acetaminophen and 0.5mg/kg of intravenous (IV) ketorolac. Post-operatively, the patient had an uneventful PACU stay and was admitted to the surgical floor. He did not require IV opioids and was eventually discharged on postoperative day 1 after receiving only one oral dose of 0.1mg/kg hydrocodone/acetaminophen to aid with swallowing.
Discussion: This case illustrates a successful multimodal analgesic approach for a complex patient undergoing major surgeries. There were many things to consider in this patient such as one functioning transplanted kidney, OSA, post laparotomy pain, post tonsillectomy pain, and post tonsillectomy bleeding. Opioids are often the analgesic of choice after surgery. We chose to minimize the administration of opioids because of the patient’s severe OSA and were able to successfully manage his laparotomy pain with a high-volume caudal block. Hong et al. showed that larger volumes with lower concentrations of local anesthetics provided better quality and longer duration of caudal analgesia (2). The administration of ketorolac was useful in our case for both the laparotomy and adenotonsillectomy. Although controversial in prior literature, a recent meta-analysis by Chan et al. demonstrated that ketorolac did not increase the incidence of post-tonsillectomy hemorrhage in pediatric patients (3). In addition, patients who received ketorolac required less opioid without an increased risk of acute renal failure following nephrectomy (4).
References:
1. Anesth Analg 2009; 109(1): 60-75.
2. Anesth Analg 2009; 109(4): 1073-8.
3. Laryngoscope 2014; 124: 1789-1793.
4. J Urol 2004; 171: 1062-1065.
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