E Letters to the Editor The Elephant in the Room Is Bigger Than You Think: Finding Obstructive Sleep Apnea Patients Dead in Bed Postoperatively To the Editor

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he recent editorial by Brown et al.1 and articles by Cote et al.2 and Goldman et al.3 highlight the tragedy of finding pediatric patients with obstructive sleep apnea (OSA) dead in bed (DIB) at home after adenotonsillectomy (“the elephant in the room,” as defined by Brown et al.).1 The OSA-DIB “elephant in the room” problem, however, is significantly larger, involving all patients with severe OSA undergoing all operations. More specifically, the prototypical DIB case is a morbidly obese adult patient with severe OSA and a painful incision who is receiving opioids and in an isolated environment without continuous electronic monitoring, continuous oxygen supplementation, and continuous positive airway pressure. The Society for Anesthesia and Sleep Medicine was formed in 2010 and tasked a multidisciplinary committee to create a national registry of OSA-DIB and “near-miss” cases to provide “insight regarding the scope,” identify “factors associated with the problem,” and determine “what can be done to limit these adverse events.” The OSA-DIB “near-miss” registry is cosponsored by the Anesthesia Quality Institute. All cases should be submitted to the registry committeea via completion of a detailed questionnaire for approval and inclusion into the database. Jonathan L. Benumof, MD Department of Anesthesiology UCSD Medical Center San Diego, California [email protected] REFERENCES 1. Brown KA, Brouillette RT. The elephant in the room: lethal apnea at home after adenotonsillectomy. Anesth Analg 2014;118:1157–9 2. Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: Houston, we have a problem! Anesth Analg 2014;118:1276–83 3. Goldman JL, Baugh RF, Davies L, Skinner ML, Stachler RJ, Brereton J, Eisenberg LD, Roberson DW, Brenner MJ. Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention. Laryngoscope 2013;123:2544–53

a Available at: http://depts.washington.edu/asaccp/projects/obstructivesleep-apnea-osa-death-near-miss-registry. Accessed January 2015.

DOI: 10.1213/ANE.0000000000000461

February 2015 • Volume 120 • Number 2

In Response We agree with Dr. Benumof1 that adult patients with severe obstructive sleep apnea (OSA) are also at risk for death while recovering from surgery and applaud the development of the OSA Death and Near Miss Registry for patients older than 17 years. The inclusion of children and adolescents in this registry might help determine the relative size of the adult and pediatric OSA “elephants.” Dr. Benumof’s prototypical case1 and many of the cases of death and neurologic injury reported by Coté et al.2 were suspected of having OSA, were given opioids, and were discharged from the recovery room to an unmonitored environment. By contrast, practice guidelines recommend that these patients should not be discharged unmonitored from the recovery area.3,4 Practicing anesthesiologists overwhelmingly agree that “hospitalized patients who are at increased risk of respiratory compromise from OSA should have continuous pulse oximetry monitoring after discharge from the recovery room” and recognize that the administration of continuous opioids constitutes a risk in the patient with severe OSA.4 Coté et al.2 speculate that clinical judgment might be clouded by performance pressure. Measures to prevent perioperative respiratory compromise, however, will only be taken if high-risk status is recognized. For some patients, OSA may not be diagnosed, and for others, the severity of OSA may go unrecognized without laboratory testing for sleep-disordered breathing. Competent clinicians can identify morbid obesity, genetic, neurologic, craniofacial, and other comorbidities that place patients at risk for perioperative respiratory compromise. Systematic reviews have consistently reported that in children, however, the accurate diagnosis of OSA and the assessment of the severity of OSA require that clinical judgment be supplemented by sleep laboratory testing.5,6 We have developed a cost-effective strategy to mitigate perioperative risk in children undergoing adenotonsillectomy—the McGill Oximetry Score. This system supplements a careful clinical assessment with home nocturnal pulse oximetry performed by the parents. Compared with polysomnography, this costeffective strategy reduces sleep laboratory technician time 10-fold, identifies children at greatest risk for perioperative respiratory complications, prioritizes the surgical intervention, and informs anesthetic management.7,8 The McGill Oximetry Score has yet to be tested in a randomized controlled trial. Further validation including the comparison of our approach with clinical judgment alone is needed. Funding: Dr. Brown is supported by the Queen Elizabeth Hospital Foundation of Montreal Chair in Pediatric Anesthesia. Conflicts of Interest: Dr. Brouillette has stock in and is a board member of PHDMedical, a Canadian company that provides TeleHealth services, mainly to US prisons. The company has also developed oximetry analysis software and an expert system for diagnosing pediatric sleep apnea. The latter two activities are not currently commercialized, and there are no plans at present to commercialize them. DOI: 10.1213/ANE.0000000000000459

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