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 cost-effective 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. Karen A. Brown, MD Department of Pediatric Anesthesia Montreal Children’s Hospital McGill University Health Centre Montreal, Quebec, Canada [email protected] Robert T. Brouillette, MD Department of Pediatrics McGill University Montreal, Quebec, Canada

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