Perioperative Acetaminophen and Dexmedetomidine Eliminate Post-Operative Opioid Requirement following Pediatric Tonsillectomy.

Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period.

Parturient With Barnes Syndrome (Thoracolaryngopelvic Dysplasia) Undergoing Cesarean Delivery of a Neonate With Barnes Syndrome: A Case Report.

This case describes a parturient with Barnes syndrome, a rare disorder characterized by subglottic stenosis, thoracic dystrophy, and small pelvic inlet, who underwent cesarean delivery of a neonate diagnosed with Barnes syndrome. Live simulation training was performed by multidisciplinary team to prepare for the spinal anesthetic, personnel flow between 2 operating rooms, and management of various airway scenarios for the newborn. After delivery, the neonate underwent laryngoscopy-bronchoscopy with successful intubation in the operating room because of labored breathing. Airway evaluation revealed subglottic stenosis, tracheomalacia/bronchomalacia. Collaboration among perinatologists, obstetric/pediatric anesthesiologists, pediatric head and neck surgeons, and neonatologists was integral to perioperative management of both the mother and child.

Comparison of early and late extubation following single-stage anterior laryngotracheoplasty.

OBJECTIVE: To compare the outcomes of early versus late extubation after primary single-stage anterior laryngotracheoplasty (LTP) using thyroid ala graft performed at our tertiary care academic children's hospital. METHODS: Twenty-five pediatric patients underwent single-stage anterior LTP using thyroid ala grafts between September 2002 and June 2009. Initial trials of extubation were attempted in 15 patients on or prior to postoperative day (POD) 2 and in 10 patients on or after POD 3. The main outcome measures analyzed in this retrospective comparison study were complication rate, length of hospitalization, reintubation during hospitalization, need for additional airway procedures, and overall decannulation rate. RESULTS: The rates of various complications in each group were not statistically significant, with the exception of methadone taper. No patients in the early extubation group and four patients in the late extubation group required methadone taper [p<0.05]. The average length of hospitalization after extubation for the early extubation group was 16.5 days [SD=14.0] and 14.6 days [SD=7.7] for the late extubation group [p>0.05]. Six patients (40%) in the early extubation group and two (20%) in the late extubation group needed reintubation at some point during hospitalization post-LTP [p>0.05]. Ten patients [66.7%] in the early extubation group and eight [80%] in the late extubation group required additional airway procedures post-LTP [p>0.05]. Ultimately, 12 (80%) of the early extubation group and nine (90%) of the late extubation group were successfully decannulated at the time of most recent follow-up [p>0.05]. CONCLUSIONS: The differences in length of hospitalization, need for additional procedures, reintubation during hospitalization and overall decannulation rate between the early and late extubation groups after single-stage anterior LTP with thyroid ala graft were not statistically significant. Methadone taper was the only complication that was statistically significantly higher in the late extubation group.

Pediatric primary anterior laryngotracheoplasty: Thyroid ala vs costal cartilage grafts.

OBJECTIVE: To compare outcomes with the use of thyroid ala cartilage (TAC) and costal cartilage (CC) grafts in pediatric primary anterior laryngotracheoplasty (LTP). DESIGN: Retrospective comparison study. SETTING: Tertiary, academic children's hospital. PATIENTS: Of 45 laryngotracheal operations performed between June 2001 and October 2008 for laryngotracheal stenosis, 29 were primary anterior LTPs. The procedures used either TAC (n = 24) or CC (n = 5) grafts and were planned as either single-stage (TAC group, 22 patients; CC group, 2 patients) or multistage (TAC group, 2 patients; CC group, 3 patients). MAIN OUTCOME MEASURES: Operative time, length of intubation, graft-specific complications, need for additional airway procedures, and overall decannulation rate. RESULTS: The mean (SD) operative times were 222 (56) minutes for TAC grafts and 363 (59) minutes for CC grafts (P = .005). For single-stage LTPs that were decannulated, the mean (range) length of intubation was 3.3 (1-11) days for TAC grafts (n = 18) and 3 (1-5) days for CC grafts (n = 2) (P = .90). Graft-specific complications occurred in 17% of TAC grafts (n = 4) and 20% of CC grafts (n = 1) (alpha > 0.05). Symptomatic stenosis requiring additional surgical intervention occurred in 43% of TAC grafts (n = 10) and 60% of CC grafts (n = 3) (alpha > 0.05). Patients underwent decannulation in 83% of TAC grafts (n = 19) and 80% of CC grafts (n = 4) (alpha > 0.05). CONCLUSIONS: In primary anterior LTPs, TAC grafts require significantly less operative time than CC grafts (P = .005). There were no statistically significant differences in length of intubation, frequency of graft-specific complications, or decannulation rates between TAC and CC grafts in primary anterior LTPs.

Comparison of intraoperative bleeding between microdebrider intracapsular tonsillectomy and electrocautery tonsillectomy.

OBJECTIVES: We sought to assess the quantity of intraoperative bleeding from microdebrider intracapsular tonsillectomy (IT) relative to electrocautery tonsillectomy (ET). METHODS: Intraoperative tonsil bleeding was measured prospectively for all children younger than 19 years of age who underwent primary tonsillectomy for recurrent tonsillitis or adenotonsillar hypertrophy at a tertiary care academic children's hospital. We performed IT in 57 patients (33 male, 24 female; mean age, 64.3 months) and ET in 51 patients (20 male, 31 female; mean age, 92.4 months). RESULTS: Microdebrider IT resulted in more intraoperative bleeding than ET (27.9 versus 8.7 mL, p = 0.003; and 1.2 versus 0.2 mL/kg, p <0.001). The median and maximum blood losses, respectively, were 0.6 and 9.5 mL/kg for IT and 0 and 2.0 mL/kg for ET. Blood loss for ET was not related to whether a resident versus an attending physician was the operating surgeon (p = 0.11). A linear regression model did not demonstrate greater bleeding with recurrent tonsillitis (IT, p = 0.39; ET, p = 0.89) or with increased patient age (IT, p = 0.08; ET, p = 0.62). CONCLUSIONS: Microdebrider IT produces more intraoperative bleeding than ET. The difference in blood loss is statistically but not clinically significant. Microdebrider IT causes bleeding within acceptable limits, and thus patients and physicians should not be discouraged from choosing this procedure solely on the basis of the amount of intraoperative blood loss.