Abstract
Background
Adenotonsillectomy (T&A) is a common surgery performed for obstructive sleep apnea (OSA) in children. Obese children are at increased risk for OSA, but are also at increased risk for cardiovascular changes that might heighten their risk of undergoing a general anesthetic. There is currently no standard of care recommendation for cardiac workup prior to T&A.
Purpose
To ascertain whether a preoperative cardiac workup is predictive of postoperative complications in obese children undergoing T&A for OSA.
Design
Retrospective cohort review.
Material and Methods
241 children with BMI ≥ 25 kg/m 2 underwent T&A for OSA. This cohort was divided into three groups — those who had no preoperative cardiac evaluation, those who had a preoperative cardiac evaluation but no significant findings and those who had a preoperative cardiac evaluation with at least one significant finding. Postoperative cardiac-related complications were compared between the three groups.
Results
There were significantly more postoperative complications in Group 3, the group with findings on preoperative cardiac evaluation. However, these were heavily weighted toward “hospital stay > 24 hours” without clear cardiac sequelae. Notably there were no incidents of pulmonary edema, re-intubation postoperatively or death.
Conclusion
In obese children undergoing T&A at a tertiary care center, a preoperative cardiac workup was not shown to be beneficial in predicting postoperative complications.
1
Introduction
Obstructive sleep apnea (OSA) is a common indication for adenotonsillectomy (T&A) among obese children . Chronic OSA can lead to many adverse cardiovascular adaptations due to the hypoxemia that it creates — pulmonary arteriolar constriction, increase in pulmonary vascular resistance and pulmonary arterial hypertension. These changes in turn lead to right ventricular hypertrophy with or without dilation and/or tricuspid insufficiency. If left unchecked, these will ultimately lead to right ventricular dysfunction and right heart failure, often called cor-pulmonale . Additionally, a variety of left ventricular adaptive changes with evidence of subclinical systolic and diastolic dysfunction are also reported with OSA .
Obesity itself is also a risk factor for both OSA and similar cardiopulmonary adaptations in children .
These cardiac changes can potentially heighten the intraoperative anesthetic risk with propensity for post-operative complications due to acute pulmonary edema, cardiac failure, arrhythmias and death .
Surgeons and anesthesiologists consider an array of pre-operative options to detect these adaptive and occult cardiac changes in an attempt to manage these patients better during the intra and post-operative period . These include preoperative cardiac consultation and obtaining an array of cardiac tests — chest X-ray (CXR), electrocardiogram (EKG) or an echocardiogram (ECHO). However, there is no consensus on who is an appropriate candidate for such testing, nor what testing (if any) is appropriate in the pre-operative setting. The decision for cardiac testing in obese patients prior to T&A is often at the discretion of the otolaryngologist.
The objective of this study was to investigate the association between pre-operative cardiac findings and postoperative outcome in obese patients undergoing T&A. We hypothesized that if such a correlation existed, pre-operative cardiac evaluation would be justified and useful in perioperative management of this patient cohort.
2
Material and methods
This study was approved by the Baylor College of Medicine Institutional Review Board. A retrospective chart review of patients who attended the Pediatric Otolaryngology Clinic at the Texas Children’s Hospital over a 5 year period beginning in January 2006 was carried out. We included patients with body mass index (BMI) ≥ 25 kg/m 2 who had a T&A primarily for OSA. We excluded patients with BMI < 25 kg/m 2 (14), surgical indication other than OSA, adenoidectomy alone, and those with active or untreated cardiopulmonary disease.
This cohort of children with BMI ≥ 25 kg/m 2 who had T&A for OSA, was then divided into three groups:
- Group 1
Patients who had no preoperative cardiac evaluation.
- Group 2
Patients who had at least one form of preoperative cardiac evaluation — CXR, EKG, ECHO or cardiac consultation, with NO significant findings.
- Group 3
Patients who had at least one form of preoperative cardiac evaluation — CXR, EKG, ECHO or cardiac consultation, with at least one significant finding.
Significant cardiac findings on standard PA and lateral chest X-rays were defined as right atrial or ventricular dilation, prominent appearance of the pulmonary artery, and pulmonary edema. Significant cardiac findings on standard 15-lead EKG were defined as right ventricular hypertrophy with or without strain pattern. Significant cardiac findings on standard transthoracic ECHO were defined as right ventricular dilation/hypertrophy, tricuspid regurgitation, and pulmonary artery hypertension. All of the above studies were reviewed by a pediatric cardiologist blinded to the clinical data, the surgery, and the post-operative outcome.
Postoperative complications were defined as hospital stay > 24 hours, increased oxygen requirement (for > 12 hours), need for postoperative cardiopulmonary evaluation by CXR, EKG or ECHO, need for postoperative cardiology consultation, evidence of pulmonary edema, need for re-intubation, and death.
The mean BMIs of the three groups were compared via the Wilcoxon rank test. The above postoperative complications were compared via the Fisher’s exact test.
2
Material and methods
This study was approved by the Baylor College of Medicine Institutional Review Board. A retrospective chart review of patients who attended the Pediatric Otolaryngology Clinic at the Texas Children’s Hospital over a 5 year period beginning in January 2006 was carried out. We included patients with body mass index (BMI) ≥ 25 kg/m 2 who had a T&A primarily for OSA. We excluded patients with BMI < 25 kg/m 2 (14), surgical indication other than OSA, adenoidectomy alone, and those with active or untreated cardiopulmonary disease.
This cohort of children with BMI ≥ 25 kg/m 2 who had T&A for OSA, was then divided into three groups:
- Group 1
Patients who had no preoperative cardiac evaluation.
- Group 2
Patients who had at least one form of preoperative cardiac evaluation — CXR, EKG, ECHO or cardiac consultation, with NO significant findings.
- Group 3
Patients who had at least one form of preoperative cardiac evaluation — CXR, EKG, ECHO or cardiac consultation, with at least one significant finding.
Significant cardiac findings on standard PA and lateral chest X-rays were defined as right atrial or ventricular dilation, prominent appearance of the pulmonary artery, and pulmonary edema. Significant cardiac findings on standard 15-lead EKG were defined as right ventricular hypertrophy with or without strain pattern. Significant cardiac findings on standard transthoracic ECHO were defined as right ventricular dilation/hypertrophy, tricuspid regurgitation, and pulmonary artery hypertension. All of the above studies were reviewed by a pediatric cardiologist blinded to the clinical data, the surgery, and the post-operative outcome.
Postoperative complications were defined as hospital stay > 24 hours, increased oxygen requirement (for > 12 hours), need for postoperative cardiopulmonary evaluation by CXR, EKG or ECHO, need for postoperative cardiology consultation, evidence of pulmonary edema, need for re-intubation, and death.
The mean BMIs of the three groups were compared via the Wilcoxon rank test. The above postoperative complications were compared via the Fisher’s exact test.
3
Results
During our 5-year study period, 1989 children underwent T&A for OSA. Of these, 241 patients (12%) were identified with BMI ≥ 25 kg/m 2 and formed the study group. The age range was from 3 to 18 years (median 10).
Of these patients 63 underwent preoperative EKG and/or ECHOs, and 52 underwent preoperative CXRs with findings summarized below in Table 1 . Of the 63 patients who underwent preoperative EKG and/or ECHO, 70% had tricuspid regurgitation and 11% had right ventricular dilation. No pulmonary artery hypertension was seen. Of the 52 patients who underwent preoperative CXR, only 1 patient was found to have right atrial or ventricular dilation on CXR. There was no evidence of pulmonary edema or prominent pulmonary artery.
| Cardiac Findings | Number of Patients (%) |
|---|---|
| Preop EKG/ECHO (N = 63) | |
| Right ventricular dilation/hypertrophy | 7 (11%) |
| Tricuspid regurgitation | 44 (70%) |
| Pulmonary artery hypertension | 0 (0%) |
| Preop CXR (N = 52) | |
| Right atrial or ventricular dilation | 1 (2%) |
| Prominent pulmonary artery | 0 (0%) |
| Pulmonary edema | 0 (0%) |
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