NM-211
OPIATE-OBVIATING ANESTHETIC FOR TONSILLECTOMY AND ADENOIDECTOMY (T&A) IN AN OBESE CHILD WITH EXTREME OBSTRUCTIVE SLEEP APNEA
Kleiman Z, Moore R, Davis C
Washington University School of Medicine, Saint Louis, Missouri, USA
Introduction:
Post-operative apnea after tonsillectomy performed in the setting of obstructive sleep apnea (OSA) is a significant issue and has resulted in profound morbidity and mortality. The risk of apneic events is heightened by comorbid obesity and the perioperative administration of opiates 1. We would like to a report an opiate-obviating anesthetic that was administered to an obese, 13-year-old with Down’s syndrome and severe OSA.
Case:
Patient D.B. is a 13-year-old male with a history of Trisomy 21, a body mass index (BMI) of 38, and OSA. The first procedure resulted in residual adenoid and tonsillar tissue along with continual snoring and apneic spells resulting in apnea/hypopnea index (AHI) of 122.3, nadir oxygen saturation of 34%, average oxygen saturation of 76%, all suggesting a diagnosis of extreme OSA. At the time of his second T&A, he was induced with propofol, ketamine, and lidocaine. Near total occlusion of his airway during spontaneous ventilation was noted on endoscopy before receiving dexamethasone, acetaminophen, and a lidocaine infusion at 1 mg/kg/hr. He was extubated and transferred to the post-anesthesia care unit (PACU) with 0/10 pain on the visual analog scale (VAS) and received no additional analgesics. Acetaminophen and ibuprofen were given when pain scores were at their most severe of 4/10. No opiates were prescribed at discharge. Thus, an entirely opioid-free course with adequate analgesia was provided.
Discussion:
We employed an analgesic regimen combining acetaminophen, ketamine and lidocaine; selected based on the most current evidence based research for opiate-sparing effects in tonsillectomies 2,3. Opiates were not required intraoperatively or postoperatively, suggesting a possible lasting analgesic effect of lidocaine and ketamine as seen in patients treated for chronic pain syndromes 4. There is no existing literature reporting similar opiate-obviating techniques in such a high risk patient. In light of the scope and significance of problems associated with perioperative apnea in this population, further study of this regimen should be pursued.
1. Cote CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: Houston, we have a problem! Anesth Analg. 2014; 118 6: 1276– 1283.
2. Elshammaa N, Chidambaran V, Housny W, et al. Ketamine as an adjunct to fentanyl improves postoperative analgesia and hastens discharge in children following tonsillectomy - a prospective, double-blinded, randomized study. Paediatr Anaesth 2011; 21: 1009–1014.
3. Hack, H. An Audit of the Use of an Opiate Sparing, Multimodal analgesic regime in children with Sleep Disordered Breathing/Obstructive Sleep Apnoea undergoing adenotonsillectomy. International Journal of Pediatric Otorhinolaryngology 78, 119–123 (2014).
4. Rickard, J. P. & Kish, T. Systemic Intravenous Lidocaine for the Treatment of Complex Regional Pain Syndrome. American Journal of Therapeutics 23, 1266–1269 (2016).
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