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Death or Neurologic Injury after Tonsillectomy in Children with a Focus on Obstructive Sleep Apnea: Houston, We Have a Problem!

Coté, Charles J. MD*; Posner, Karen L. PhD; Domino, Karen B. MD, MPH

doi: 10.1213/ANE.0b013e318294fc47
Pediatric Anesthesiology: Research Report

BACKGROUND: Obesity is epidemic in the United States and with it comes an increased incidence of obstructive sleep apnea (OSA). Evidence regarding opioid sensitivity as well as recent descriptions of deaths after tonsillectomy prompted a survey of all members of the Society for Pediatric Anesthesia regarding adverse events in children undergoing tonsillectomy.

METHODS: An electronic survey was sent to 2377 members of the Society for Pediatric Anesthesia. Additionally, data from the American Society of Anesthesiologists Closed Claims Project were obtained. Adverse events during or after tonsillectomy with or without adenoidectomy in children were included. Children at risk for OSA were identified as either having a positive history for OSA or a post hoc application of the American Society of Anesthesiologists OSA practice guidelines. These children were compared with all other children by Fisher exact test for proportions and t test for continuous variables.

RESULTS: A total of 129 cases were identified from the 731 replies to the survey, with 92 meeting inclusion criteria for having adequate data. Another 19 cases with adequate data were identified from the 45 from the American Society of Anesthesiologists Closed Claims Project. A total of 111 cases were included in the final analysis. Death and permanent neurologic injury occurred in 86 (77%) cases and were reported in the operating room, postanesthesia care unit, on the ward, and at home. Sixty-three (57%) children fulfilled American Society of Anesthesiologists criteria to be at risk for OSA. Children categorized as at risk for OSA were more likely than other children to be obese and to have comorbidities (P < 0.0001). A larger proportion of at risk children had the event attributed to apnea (P = 0.016), whereas all others had a larger proportion of events attributed to hemorrhage (P = 0.006).

CONCLUSIONS: Deaths or neurologic injury after tonsillectomy due to apparent apnea in children suggest that at least 16 children could have been rescued had respiratory monitoring been continued throughout first- and second-stage recovery, as well as on the ward during the first postoperative night. A validated pediatric-specific risk assessment scoring system is needed to assist with identifying children at risk for OSA who are not appropriate to be cared for on an outpatient basis.

Supplemental Digital Content is available in the text.Published ahead of print July 10, 2013

From the *Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School/The MassGeneral Hospital for Children, Boston, Massachusetts; and Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.

Accepted for publication March 25, 2013.

Published ahead of print July 10, 2013

Funding: Supported in part by the American Society of Anesthesiologists (ASA), Park Ridge, IL. All opinions expressed are those of the authors and do not reflect the policy of the ASA.

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site.

Reprints will not be available from the authors.

Address correspondence to Charles J. Coté, MD, Department of Anesthesia and Critical Care, The MassGeneral Hospital for Children, 55 Fruit St., Boston, MA 02114. Address e-mail to

© 2014 International Anesthesia Research Society