Use of the pediatric intensive care unit for post-procedural monitoring in young children following microlaryngobronchoscopy: Impact on resource utilization and hospital cost

Objective: To assess the frequency of post-procedural complications, medical interventions, and hospital costs associated with microlaryngobronchoscopy (MLB) in children prophylactically admitted for pediatric intensive care unit (PICU) monitoring for age ≤ 2 years. Methods: We performed a single-center, retrospective, descriptive study within a 44-bed PICU in a stand-alone, tertiary, pediatric referral center. Inclusion criteria were age ≤2 years and pre-procedural selection of prophylactic PICU monitoring after MLB between January 2010 and December 2015. Children were excluded for existing tracheostomy, if undergoing concurrent non-otolaryngeal procedures, or if intubated at the time of PICU admission. Primary outcomes were the development of major and minor procedural complications and medical rescue interventions. Secondary outcomes were hospital cost and length of stay (LOS). Results: One hundred and eight subjects met inclusion criteria with a median age of 5.3 (IQR: 2.6–10.9) months. A majority (86%) underwent therapeutic instrumentation in addition to diagnostic MLB. There were no observed major complications or rescue interventions. Minor complications were noted within 5 h of monitoring and included isolated stridor (24%), desaturation <90% (10%), and nausea/emesis (8%). Minor interventions included supplemental oxygen via regular nasal cannula (39%), single-dose inhaled racemic epinephrine (19%), single-dose systemic corticosteroids (19%), or high flow nasal cannula (HFNC) therapy (4%). Save for two cases of HFNC, interventions were completed or discontinued within 5 h. Median PICU LOS was 1.1 days and median cost was $9650 (IQR: $8235- $14,861) per encounter. Estimated cost of same day observation in our post anesthesia care unit (PACU) following MLB without PICU admission is $1921 per encounter. Conclusions: In children ≤ 2 years of age prophylactically admitted for PICU observation, we did not observe severe complications or major interventions after MLB. Minor interventions and complications were noted early during post-procedural monitoring. PICU monitoring was substantially more expensive than same-day PACU observation. Young age as the sole criteria for prophylactic PICU monitoring after diagnostic or therapeutic MLB may be unjustified when comparable, cost-conscious care can be achieved in a PACU setting. Prior to pre-procedural selection of PICU monitoring, we recommend a broad contextual risk assessment including a review of comorbidities, operative plan, and intended anesthetic exposure.