Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement.

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

Implementing Telemedicine During the COVID-19 Pandemic: Disparities in Utilization in an Urban Pain Medicine Practice.

Purpose: The COVID-19 pandemic led to a drastic expansion in utilizing telemedicine, circumventing some of the geographical barriers to accessing pain care. However, uncertainties around the impact of telemedicine across various sociodemographic groups still exist, prompting further exploration. Therefore, this study aimed to evaluate the impact of sociodemographic factors in telemedicine utilization during and after the COVID-19 pandemic. Patients and methods: All outpatient non-procedural visits at the pain medicine division of a large academic institution in the epicenter of the pandemic (New York, USA), between March 2019 and October 2021, were retrospectively included. Sociodemographic data including gender, age, ethnicity/race, postal code, and type of health insurance, across three time periods associated with the COVID-19 pandemic - pre-lockdown (in-office visits only), lockdown (telemedicine visits only) and post-lockdown (offering both in-office and telemedicine visits) - were analyzed and compared. Results: In total, 12,615 unique patients - The majority being women (58%) - were seen during the whole study period. In the post-lockdown period, telemedicine was utilized by 42% of all patients. Follow-up visits, younger patients, white patients, patients residing further away from the hospital, and privately insured patients were more likely to utilize telemedicine post-lockdown (p <0.05). Older patients, minorities, Manhattan residents, and Medicare/Medicaid recipients, were more likely to use in-office visits post-lockdown (p <0.05). Conclusion: We identified disparities in the utilization of telemedicine in Pain Medicine, which may be due to socioeconomic factors such as lack of access to reliable internet access, cost of devices, and technological know-how. This emphasizes the need for further studies to better understand the reasons for and barriers to telemedicine use. This could help inform policymaking to safeguard equitable access to telemedicine use for pain care.

Paralysis Versus Non-Paralysis Anesthesia for Operative Laryngoscopy: A Randomized Controlled Trial.

OBJECTIVE: To compare outcomes between two standard-of-care anesthesia regimens for operative laryngoscopy: general anesthesia with a neuromuscular blocking agent (NMBA) versus remifentanil and propofol (non-NMBA). METHODS: This was a prospective, single-blinded, randomized controlled trial at a tertiary care center. Patients were randomized to either anesthesia using rocuronium (NMBA) or with remifentanil/propofol infusion alone (non-NMBA). Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected. RESULTS: Sixty-one patients who underwent suspension laryngoscopy from 2020 to 2022 were included (25 female, 36 male, ranging 20-81 years). Thirty patients were enrolled in the NMBA arm and 31 patients in the non-NMBA arm. Heart rate and mean arterial pressure were higher in the NMBA (p < 0.01). Patients in the non-NMBA group were more likely to require vasopressors (p = 0.04, RR = 3.08 [0.86-11.05]). Surgeons were more frequently satisfied with conditions in the NMBA group (86.7%) compared to the non-NMBA group (58.1%, p < 0.01). Procedures were more likely to be paused due to movement in the non-NMBA group (45.1%) compared to the NMBA group (16.6%, p < 0.03, RR = 2.26 [1.02-4.99]). Patients in the non-NMBA group were more likely to endorse myalgia the week after surgery (44%) compared to the NMBA group (8.3%, p < 0.01) and reported higher average pain levels on a 0-10 pain scale (3.7) compared to the paralysis group (2.0). CONCLUSIONS: Anesthesia with rocuronium was associated with better intraoperative conditions and postoperative pain compared to anesthesia with remifentanil/propofol. Remifentanil/propofol were associated with lower blood pressure and suppression of laryngoscopy-associated tachycardia. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:2654-2664, 2023.

The effect of nitrous oxide on the dose-response relationship of rocuronium.

It has been generally assumed that nitrous oxide (N(2)O) enhances the effects of nondepolarizing muscle relaxants only weakly if at all. More recent evidence suggests that drug potency may be more intense under N(2)O anesthesia compared with total IV anesthesia (TIVA). However, the magnitude of this effect has not been well defined. We measured the 50% effective dose of rocuronium in 35 patients receiving N(2)O-propofol-opioid anesthesia and a comparable group receiving TIVA. A single dose of rocuronium was given to each patient and drug potency was calculated for each individual from the Hill equation assuming a log-dose/logit slope of 4.5. In both groups, the relaxant was administered 15 min after induction of anesthesia. Neuromuscular function was measured using electromyography with single stimuli at 0.10 Hz. We measured a 50% effective dose of 0.209 +/- 0.051 mg/kg during TIVA and of 0.166 +/- 0.041 mg/kg during N(2)O anesthesia, a decrease of 20% (P < 0.001). The clinical importance of this effect must be considered modest; however, estimates of potency that are usually obtained during N(2)O anesthesia may underestimate drug requirements at the time of induction of anesthesia.