Severe OSA for adenotonsillectomy6-year-old boy, 38 kg (above the 99th centile), for elective adenotonsillectomy

The patient

The examiner asks

Answer aloud, then press Show.

1. Consider

   What are your concerns?

   Show the answerHide the answer

   • An obese 6-year-old with severe OSA, AHI 24, booked as a day case for adenotonsillectomy. Patient
   • At 6 with obesity and OSA, he obstructs fast at induction and is opioid-sensitive.
   • An AHI of 10 or more is severe in a child; his 24, nadir 78%, is well past it. Disease
   • Long-standing OSA can cause cor pulmonale, so I look for it.
   • The surgeon shares his airway under a gag, and blood follows. Surgery

2. Prepare

   Is this booking right, and what else do you need?

   Show the answerHide the answer

   • Not a day case: AHI 10 or more, or a nadir below 80%, means admission; he has both. Stem trigger
   • Any cardiac history or signs of right heart strain: ECG and echo first. Disease
   • Sedative premedication only with care and monitoring, given his breathing. Patient
   • Monitored bed with continuous oximetry booked for tonight. After surgery

3. Plan

   How do you conduct the anaesthetic?

   Show the answerHide the answer

   • Gas induction, oral airways of several sizes and CPAP ready for early obstruction. Airway
   • Cuffed tube to keep blood out of his lungs.
   • Opioid reduced by up to half and titrated, not given as a fixed dose. Disease
   • Paracetamol 15 mg/kg IV; no codeine for him, now or at discharge. After surgery
   • Dexamethasone at up to 1 mg/kg, maximum 20 mg, for swelling and vomiting; ondansetron 50–100 mcg/kg.
   • Extubated awake, on his side, after suctioning his pharynx.

4. Crisis

   In recovery, after morphine for pain, he snores, then stops; SpO2 84%, RR 6, HR 110. What do you do?

   Show the answerHide the answer

   • Opioid-induced obstruction and hypoventilation: stimulate him, jaw thrust, 100% oxygen. Crisis
   • Turn him on his side; CPAP to splint his upper airway.
   • Bag-mask breaths if his breathing stays slow.
   • Naloxone 1–5 mcg/kg IV, titrated to breathing so his analgesia isn't lost.
   • Naloxone is short-acting: continuous oximetry in a monitored bed for recurrence. After surgery