Anesthesiological considerations for children with obstructive sleep apnea.

OBJECTIVE

To summarize recent evidence-based data regarding outcomes associated with children who have obstructive sleep apnea (OSA).

RESULTS

Internet surveys conducted by pediatric otolaryngologists and pediatric anesthesiologists have reported a disturbing number of deaths within 24 h of tonsillectomy attributed to postsurgical/anesthesia apnea. Several occurred in the post anesthesia care unit after routine monitors had been removed. In addition, a number of deaths also have been attributed to children who have duplicated cytochromes allowing the rapid conversion of codeine to morphine, thus producing a relative drug overdose. Finally, there is some human and animal evidence suggesting that repeated episodes of hypoxemia result in altered opioid receptors causing relative opioid sensitivity. These factors have important clinical implications.

CONCLUSIONS

Perioperative deaths in children with OSA occur at a low frequency. Hypoxia-induced opioid sensitivity combined with an approximate 1-2% incidence of rapid conversion of codeine to morphine suggest the need for new approaches for providing preoperative assessment of risk, extended postoperative observation and the need for alternative opioids to codeine. Additionally, new less painful surgical approaches may help to reduce postoperative opioid requirements and therefore perhaps less risk for opiate-induced apnea in this vulnerable population.