加强型喉罩用于小儿扁桃体腺样体切除术的效果及安全性

目的探讨加强型喉罩用于小儿扁桃体腺样体切除术的效果及安全性。方法选择择期行扁桃体腺样体切除术的住院患儿60例,年龄4~12岁。采用随机数字表法均分为喉罩组(L组)和气管插管组(T组)。观察并记录诱导前5min(T0)、插入喉罩或气管插管时(T1)、置开口器时(T2)、手术开始时(T3)及拔除喉罩或气管插管前(T4)的HR、MAP、SpO2;记录T1~T4时的VT、PETCO2及T1~T3时的气道峰压(Ppeak);记录喉罩或气管插管首次插入成功率和总成功率、手术时间、苏醒时间、丙泊酚和瑞芬太尼的用量,并记录术中及术后呛咳、喉痉挛、反流误吸及苏醒期躁动等不良反应的发生情况。结果 L组患儿苏醒时间明显短于T组(P0.05);与T组比较,T1、T2、T4时L组HR明显减慢,T1时L组MAP明显降低(P0.05或P0.01);与T0时比较,T1、T2、T4时T组HR明显增快(P0.05);而两组SpO2、VT、PETCO2、Ppeak比较差异均无统计学意义;与T组比较,L组术后呛咳、苏醒期躁动发生率明显降低(P0.01或P0.05),而两组喉罩或气管插管首次成功率和总成功率、丙泊酚用量、瑞芬太尼用量、喉痉挛及反流误吸的发生率差异均无统计学意义。结论加强型喉罩用于小儿扁桃体腺样体切除术中,可保持气道通畅,获得良好的通气效果,血流动力学平稳,苏醒时间短,不良反应少。因此其用于该类手术中安全有效,值得在临床上推广应用。     

Postoperative tonsillectomy bleeding complications in children: A comparison of three surgical techniques

Objective & hypothesisStated in the Null form: There will be no difference in primary or secondary hemorrhage rate in children undergoing tonsillectomy or adenotonsillectomy across three surgical techniques: PEAK Plasmablade, electric monopolar cautery, coblation.Study designRetrospective chart analysis.SettingAcademic Medical Center: Children's Hospital.Subjects & methodsElectronic chart data were collected from patient's age 2–18 years who underwent tonsillectomy, with or without adenoidectomy, at a tertiary pediatric hospital between June 2011 to May 2013 by electric monopolar cautery, coblation, or PEAK PlasmaBlade. Treatment outcomes following each of these surgical approaches, relative to rate of post-operative primary and secondary bleeding, hospital admission, and emergency department visits were compared.ResultsA total of 1780 patients that had tonsillectomy or adenotonsillectomy were evaluated. There was a significant difference in bleed rate by age with older patients having more bleeding post-procedure than their younger counterparts. There was also a difference in bleeding frequency by diagnosis. Patients with a diagnosis of OSA were less likely to experience a postoperative bleed than children with either recurrent tonsillitis or both. Significance was evident between post-op hemorrhage rate and instrumentation (χ² = 11.17, df = 2, p = 0.004). The majority of bleeds occurred with coblation (58.9%), while PEAK had only 17.8% and cautery 23%.ConclusionThe null hypothesis was rejected. That is, PEAK PlasmaBlade was safe and effective, with statistically less postoperative bleeding and ED visits, especially when compared to coblation techniques. Coblation patients had the highest rates of postoperative bleeding.     

A two-year follow-up observational study of the T-14 paediatric throat disorders outcome measure in tonsillectomy and adenotonsillectomy

IntroductionThe T-14 questionnaire is a validated patient reported outcome measure used to assess the value of paediatric tonsillectomy from the patient’s perspective. There are currently limited data revealing the long-term postoperative effects of tonsillectomy on quality of life in the paediatric population. A previously published study was therefore extended to provide additional data at 12 and 24 months following surgery.MethodsA prospective uncontrolled observational study was undertaken examining 54 paediatric patients undergoing tonsillectomy at Portsmouth Hospitals NHS Trust. Parents of children having surgery were invited to complete a T-14 questionnaire preoperatively as well as at 3, 6 (previously published), 12 and 24 months postoperatively.ResultsThe questionnaire was completed for 50 of the 54 patients preoperatively as well as at 3, 6 and 12 months postoperatively, with 44 being completed at 24 months. The mean difference between the preoperative T-14 scores and the scores at 3, 6, 12 and 24 months following surgery were highly statistically significant (p<0.001).ConclusionsThis is the first study published in the literature to assess the T-14 questionnaire at 12 and 24 months following paediatric tonsillectomy, providing evidence of the ongoing benefit of patient reported outcome measures. This further confirms the value of tonsillectomy in the paediatric population and demonstrates its ongoing positive effects on quality of life.     

Relationship between obstructive sleep apnea-specific symptoms and cardiac function before and after adenotonsillectomy in children with adenotonsillar hypertrophy

Objective

The aim of our study was to investigate subclinical cardiac disturbances in patients with symptoms due to adenotonsillar hypertrophy (ATH) and the impact of adenotonsillectomy (AT) using conventional and novel echocardiographic measures.

Material and methods

Thirty patients with grade 3 or 4 ATH (mean age: 7.86 ± 3.83 years; 10 females) and 30 healthy, age- and sex-matched volunteers (mean age, 8 ± 2.77; 14 females) were enrolled in the study. In addition to conventional two-dimensional and Doppler echocardiographic parameters, tissue Doppler parameters, including myocardial performance indices (MPIs) of both the right (RV) and left ventricle (LV), were studied. The severity of obstructive sleep apnea (OSA) was determined using the OSA-18 health quality questionnaire. The OSA-18 questionnaire and echocardiographic examination were repeated after AT in patients with ATH.

Results

The total OSA-18 scores for the control, preoperative, and postoperative groups were 39.56 ± 19.98, 80.63 ± 22.32, and 44.10 ± 20.31, respectively. Conventional parameters were not different among the groups. The mean pulmonary artery pressure estimated using the Mahan formula was increased in the ATH group compared with that in the control group (21.72 ± 4.25 vs. 12.43 ± 3.83, respectively; p < 0.001) and significantly improved after AT (21.72 ± 4.25 vs. 16.09 ± 4.53; p < 0.001). The RV MPI was significantly different between the control and ATH groups (0.322 ± 0.052 vs. 0.383 ± 0.079, respectively; p = 0.001). Both the LV and RV MPI significantly improved (0.515 ± 0.066 vs. 0.434 ± 0.052, p < 0.001; and 0.383 ± 0.079 vs. 0.316 ± 0.058, p = 0.018, respectively) after surgery for ATH.

Conclusions

Our study revealed that the patients with OSA-specific symptoms due to ATH had higher pulmonary artery pressure and impaired RV function according to novel echocardiographic parameters. Surgery for ATH seems to have an important effect on both LV and RV function.     

¿Es necesario repetir el estudio de sueño de control a todos los niños con SAHOS moderado-severo tras la cirugía?

Hypertrophy of adenotonsillar tissue is the most common cause of OSAS in otherwise healthy children, and therefore adenotonsillectomy is the first line treatment. Scientific societies recommend nocturnal follow-up PSG to assess for residual OSAS in children with preoperative evidence for moderate to severe OSAS, obesity, craniofacial anomalies that obstruct the upper airway and neurological disorders, based on the increasing trend of publications reporting residual OSAS after adenotonsillectomy. Follow-up PSG values in children with a pre-operative diagnosis of severe OSAS were analysed retrospectively, and compared to the parents’ impression after ENT surgery. The study population included 41 healthy children with severe OSAS and adenotonsillar surgery. The percentage of children with normal PSG parameters (AHI < 2/h) after adenotonsillectomy was 80.48%. A very good correlation was observed between the parents’ perception after treatment and the follow-up PSG parameters, specifically when the parents perceived that the patient had shown «complete resolution» (no snoring or apnoea), 90.62% of the children had an AHI < 2/h in the follow-up PSG, the maximum residual AHI being 2.6/h. In healthy children with no underlying pathology, the information provided by the parents on clinical progression after surgery could be useful and might enable the selection of those patients who require a follow-up study, avoiding overload in sleep units.     

舒芬太尼与瑞芬太尼用于儿童扁桃体和腺样体切除术后麻醉恢复质量的比较

目的 观察舒芬太尼与瑞芬太尼在儿童扁桃体和腺样体切除术中及术后镇痛镇静作用,比较两种药物对麻醉恢复质量的影响。方法 选择择期进行扁桃体和腺样体切除术患儿80例,随机分为舒芬太尼组（S组,n=40）和瑞芬太尼组（R组,n=40）。S组以舒芬太尼0.2μg/kg快速诱导,以0.2μg·kg-1·h-1术中维持,手术结束前30分钟停药。R组以瑞芬太尼2μg/kg快速诱导,以6μg·kg-1·h-1术中维持,手术结束前5分钟停药。分别观察两组术中术后血流动力学指标及术后患儿镇痛镇静程度。结果 两组在术中血流动力学指标无明显差异（P〉0.05）。拔管后5分钟时S组MAP较基础值无明显差异;R组MAP较基础值明显增高（P〈0.05）。S组患儿在术后Ramsay评分较适宜,VAS评分较低。结论 两种药物均适用于儿童扁桃体和腺样体切除术,舒芬太尼可提高术后麻醉恢复质量。     

Management of secondary hemorrhage following pediatric adenotonsillectomy

A retrospective study was performed of all patients requiring admission to the Royal Children's Hospital, Melbourne over a 12 year period with secondary haemorrhage following adenotonsillectomy, to determine what percentage of these children received blood transfusions or were returned to the operating room to secure hemostasis, and to identify factors predictive of the need for major intervention. There were 163 children who presented from 2 to 15 days following surgery. Initial management in all cases was establishment of intravenous access, and 151 received intravenous or oral antibiotics. One hundred and forty one were managed without the need for major intervention (87%), including five who had silver nitrate cautery to the tonsillar fossae. Major intervention was required in 22 cases (13%): 5 patients were returned to the operating room for hemostasis; 15 received blood transfusions and 2 underwent both. All surgery was required within 12 h of admission and all blood transfusions within 24 h. The highest rates of major intervention were in those with fresh bleeding at the time of presentation (38%) and hemoglobin levels less than 100 g/l (36%). For those requiring admission with secondary haemorrhage, a period of observation of 24 h would probably be adequate in the majority of cases to identify those children who will require major intervention by surgery or transfusion.     

Invasive group A Streptococcus resulting in sepsis and abdominal wall abscess after adenotonsillectomy

Systemic infectious complications following adenotonsillectomy are exceedingly rare. We describe an otherwise healthy 2‐year‐old patient who developed group A beta‐hemolytic Streptococcus sepsis and presumptive scarlet fever 3 days after an uncomplicated adenotonsillectomy. After resolution of fever, rash, and discharge home on antibiotics, the patient returned on postoperative day 10 with an abdominal wall abscess. This is the first reported case of an abdominal wall abscess as a complication of adenotonsillectomy. This case demonstrates that an awareness of unexpected infectious complications of adenotonsillectomy should be a part of postsurgical management. Laryngoscope, 125:1230–1232, 2015     

Changes in salivary cortisol levels in pediatric patients with obstructive sleep apnea syndrome after adenotonsillectomy

ObjectiveObstructive sleep apnea syndrome (OSAS) activates the stress response system, including the hypothalamic–pituitary–adrenocortical (HPA) axis. The salivary cortisol, as an index of free circulating cortisol levels, may be used as a measure of HPA axis activity. We examined the change in the salivary cortisol level in pediatric OSAS patients before and after adenotonsillectomy (AT).MethodsForty-eight subjects from 80 subjects suspicious of having OSAS were diagnosed with OSAS by overnight PSG, 34 of 48 OSAS patients undergoing AT, and 13 of 34 OSAS patients were finally enrolled prospectively for this study. Before and three months after the AT, the saliva was collected at night before PSG (n-sCor) and in the early morning after PSG (m-sCor) for the measurements of the salivary cortisol level.ResultsChildren in the study population (n = 13) were divided into mild (1⩽ AHI <5, n = 5), moderate (5⩽ AHI <10, n = 3), and severe (AHI ⩾10, n = 5) OSAS groups. The mean preoperative AHI in the children was 14.7, and the mean postoperative AHI was 0.33. The percentage of children with AHI <1 after AT was 92.3%. Postoperative m-sCor, the difference of cortisol level (sub-sCor: m-sCor minus n-sCor), and the ratio of cortisol level (r-sCor: m-sCor/n-sCor) showed significant difference postoperatively.ConclusionsAT was associated with improvements in PSG and subjective symptoms in pediatric OSAS patients. In addition, these improvements were significantly related to normalization of salivary cortisol level after AT. Although further study on salivary cortisol levels needs to be done, the measurement of salivary cortisol level before and after AT may predict the outcome of AT as a treatment of OSAS.