Pediatric Perioperative Cardiac Arrest, Death in the Off Hours

Peri-operative cardiac arrest in children as reported to the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest. An activity survey estimated UK paediatric anaesthesia annual caseload as 390,000 cases, 14% of the UK total. Paediatric peri-operative cardiac arrests accounted for 104 (12%) reports giving an incidence of 3 in 10,000 anaesthetics (95%CI 2.2-3.3 per 10,000). The incidence of peri-operative cardiac arrest was highest in neonates (27, 26%), infants (36, 35%) and children with congenital heart disease (44, 42%) and most reports were from tertiary centres (88, 85%). Frequent precipitants of cardiac arrest in non-cardiac surgery included: severe hypoxaemia (20, 22%); bradycardia (10, 11%); and major haemorrhage (9, 8%). Cardiac tamponade and isolated severe hypotension featured prominently as causes of cardiac arrest in children undergoing cardiac surgery or cardiological procedures. Themes identified at review included: inappropriate choices and doses of anaesthetic drugs for intravenous induction; bradycardias associated with high concentrations of volatile anaesthetic agent or airway manipulation; use of atropine in the place of adrenaline; and inadequate monitoring. Overall quality of care was judged by the panel to be good in 64 (62%) cases, which compares favourably with adults (371, 52%). The study provides insight into paediatric anaesthetic practice, complications and peri-operative cardiac arrest.

Global neonatal perioperative mortality: A systematic review and meta-analysis

STUDY OBJECTIVE

There are large differences in health care among countries. A higher perioperative mortality rate (POMR) in neonates than in older children and adults has been recognized worldwide. The aim of this study was to provide a systematic review of published 24-h and 30-day POMRs in neonates from 2011 to 2022 in countries with different Human Development Index (HDI) levels.

DESIGN AND SETTING

A systematic review with a meta-analysis of studies that reported 24-h and 30-day POMRs in neonates was performed. We searched the databases from January 2011 to July 30, 2022.

MEASUREMENTS

The POMRs (per 10,000 procedures under anesthesia) were analyzed according to country HDI. The HDI levels ranged from 0 to 1, representing the lowest and highest levels, respectively (very-high-HDI: ≥ 0.800, high-HDI: 0.700-0.799, medium-HDI: 0.550-0.699, and low-HDI: < 0.550). The magnitude of the POMRs by country HDI was studied using meta-analysis.

MAIN RESULTS

Eighteen studies from 45 countries were included. The 24-h (n = 96 deaths) and 30-day (n = 459 deaths) POMRs were analyzed from 33,729 anesthetic procedures. The odds ratios (ORs) of the 24-h POMR in low-HDI countries were higher than those in very-high- (OR 8.4, 95% CI 1.7-40.4; p = 0.008), high- (OR 7.3, 95% CI 2.2-24.4; p = 0.001) and medium-HDI countries (OR 7.7, 95% CI 3.1-18.7; p < 0.0001) but with no odds differences between very-high- and high-HDI countries (p = 0.879), very-high- and medium-HDI countries (p = 0.915) and high- and medium-HDI countries (p = 0.689). The odds of a 30-day POMR in low-HDI countries were higher than those in very-high-HDI countries (OR 6.9, 95% CI 1.9-24.6; p = 0.002) but not in high-HDI countries (OR 1.4, 95% CI 0.6-3.0; p = 0.396).

CONCLUSIONS

The review demonstrated very high global POMRs in a surgical population of neonates independent of the country HDI level. We identified differences in 24-h and 30-day POMRs between low-HDI countries and other countries with higher HDI levels.

Management of six episodes of intraoperative cardiac arrests in an infant with traumatic bronchial rupture: A case report

RATIONALE

Traumatic bronchial rupture in infants usually necessitates surgical intervention, with few reports documenting instances of multiple cardiac arrests occurring during surgery under conditions of severe hypoxemia.

PATIENT CONCERNS

A 3-year-old boy after trauma presented with severe hypoxemia for 2 days and was urgently transferred to the operating room for surgery, 6 episodes of cardiac arrest happend during surgery.

DIAGNOSES

The baby was diagnosed with bronchial rupture based on the history of trauma, clinica manifestations, and intraoperative findings.

INTERVENTIONS

Intrathoracic cardiac compression and intravenous adrenaline were administrated.

OUTCOMES

The normal sinus rhythm of the heart was successfully restored within 1 minute on each occasion, facilitating the smooth completion of the surgical procedure. By the end of surgery, SpO2 levels had rebounded to 95% and remained stable.

LESSONS

Inadequate management of bronchial ruptures in infants frequently coincides with severe hypoxemia, necessitating immediate surgical intervention. Prompt identification and management of cardiac arrest by anesthetists during surgery is imperative to reduce mortality.

Predictors and outcomes of perioperative cardiac arrest in children undergoing noncardiac surgery

Background

Perioperative cardiac arrest continues to occur. This study aims to identify risk factors for perioperative cardiac arrest in children presenting for noncardiac surgery and characterise its outcomes.

Methods

Using the National Surgical Quality Improvement Program (NSQIP) Pediatric Database 2019 and 2020, 261 276 patients were included. Patients ≥18 yr and cardiac surgical procedures were excluded. Exploratory multivariable analysis was performed to identify independent predictors of perioperative cardiac arrest and associated outcomes.

Results

The overall rate of cardiac arrest was 0.1%, with an intraoperative rate of 0.05% and 48-h postoperative rate of 0.06%. Significant risk factors for perioperative cardiac arrest included age <12 months (adjusted odds ratios [aOR] 3.07, P<0.001), American Society of Anesthesiology Physical Status classification (ASA-PS 3 aOR=2.57, P<0.001; ASA-PS 4 aOR=5.27, P<0.001; ASA-PS 5 aOR=13.1, P<0.001), admission through the emergency room (aOR 1.7, P=0.003), inpatient (aOR 2.19, P=0.008), major and severe cardiac disease (aOR 1.58, P=0.008), impaired cognitive status (aOR 1.54, P=0.009), and longer anaesthesia duration (aOR 1.1 per 30 min, P<0.001). Perioperative cardiac arrest was significantly associated with longer hospital length of stay, reoperation, differences in discharge destination, and 30-day mortality. In addition, patients experiencing postoperative cardiac arrest had a significantly higher rate of in-hospital and 30-day mortality than those experiencing intraoperative cardiac arrest.

Conclusions

The incidence of cardiac arrest in this study is higher than previously reported. This may be related to selection bias and the rigorous data collection required by NSQIP. Lower 30-day mortality after intraoperative cardiac arrest could be related to prompt recognition and rapid initiation of intraoperative resuscitation. Identification of perioperative risk factors for cardiac arrest is crucial to improve the safety and quality of patient care.

Early warning for SpO2 decrease by the oxygen reserve index in neonates and small infants

INTRODUCTION

Continuously assessing the oxygenation levels of patients to detect and prevent hypoxemia can be advantageous for safe anesthesia, especially in neonates and small infants. The oxygen reserve index (ORI) is a new parameter that can assess oxygenation through a relationship with arterial oxygen partial pressure (PaO2 ). The aim of this study was to examine whether the ORI provides a clinically relevant warning time for an impending SpO2 (pulse oximetry hemoglobin saturation) reduction in neonates and small infants.

METHODS

ORI and SpO2 were measured continuously in infants aged <2 years during general anesthesia. The warning time and sensitivity of different ORI alarms for detecting impending SpO2 decrease were calculated. Subsequently, the agreement of the ORI and PaO2 with blood gas analyses was assessed.

RESULTS

The ORI of 100 small infants and neonates with a median age of 9 months (min-max, 0-21 months) and weight of 8.35 kg (min-max, 2-13 kg) were measured. For the ORI/PaO2 correlation, 54 blood gas analyses were performed. The warning time and sensitivity of the preset ORI alarm during the entire duration of anesthesia were 84 s (25th-75th percentile, 56-102 s) and 55% (95% CI 52%-58%), and those during anesthesia induction were 63 s (40-82 s) and 56% (44%-68%), respectively. The positive predictive value of the preset ORI alarm were 18% (95% CI 17%-20%; entire duration of anesthesia) and 27% (95% CI 21%-35%; during anesthesia induction). The agreement of PaO2 intervals with the ORI intervals was poor, with a kappa of 0.00 (95% CI = [-0.18; 0.18]). The weight (p = .0129) and height (p = .0376) of the infants and neonates were correlated to the correct classification of the PaO2 interval with the ORI interval.

CONCLUSIONS

The ORI provided an early warning time for detecting an impending SpO2 decrease in small infants and neonates in the defined interval in this study. However, the sensitivity of ORI to forewarn a SpO2 decrease and the agreement of the ORI with PaO2 intervals in this real-life scenario were too poor to recommend the ORI as a useful early warning indicator for this age group.

Global anaesthesia-related cardiac arrest rates in children: a systematic review and meta-analysis

BACKGROUND

Neonates and infants have a higher perioperative risk of cardiac arrest and mortality than adults. The Human Development Index (HDI) ranges from 0 to 1, representing the lowest and highest levels of development, respectively. The relation between anaesthesia safety and country HDI has been described previously. We examined the relationship among the anaesthesia-related cardiac arrest rate (ARCAR), country HDI, and time in a mixed paediatric patient population.

METHODS

Electronic databases were searched up to July 2022 for studies reporting 24-h postoperative ARCARs in children. ARCARs (per 10,000 anaesthetic procedures) were analysed in low-HDI (HDI<0.8) vs high-HDI countries (HDI≥0.8) and over time (pre-2001 vs 2001-22). The magnitude of these associations was studied using systematic review methods with meta-regression analysis and meta-analysis.

RESULTS

We included 38 studies with 5,493,489 anaesthetic procedures and 1001 anaesthesia-related cardiac arrests. ARCARs were inversely correlated with country HDI (P<0.0001) but were not correlated with time (P=0.82). ARCARs did not change between the periods in either high-HDI or low-HDI countries (P=0.71 and P=0.62, respectively), but were higher in low-HDI countries than in high-HDI countries (9.6 vs 2.0; P<0.0001) in 2001-22. ARCARs were higher in children aged <1 yr than in those ≥1 yr in high-HDI (10.69 vs 1.48; odds ratio [OR] 8.03, 95% confidence interval [CI] 5.96-10.81; P<0.0001) and low-HDI countries (36.02 vs 2.86; OR 7.32, 95% CI 3.48-15.39; P<0.0001) in 2001-22.

CONCLUSIONS

The high and alarming anaesthesia-related cardiac arrest rates among children younger than 1 yr of age in high-HDI and low-HDI countries, respectively, reflect an ongoing challenge for anaesthesiologists.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42021229919.

Regional Anesthesia for Neonates

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Incidences and outcomes of intra-operative vs. postoperative paediatric cardiac arrest: A retrospective cohort study of 42 776 anaesthetics in children who underwent noncardiac surgery in a Thai tertiary care hospital

BACKGROUND

The reported incidence of paediatric perioperative cardiac arrest (PPOCA) in most developing countries ranges from 2.7 to 22.9 per 10 000 anaesthetics, resulting in mortality rates of 2.0 to 10.7 per 10 000 anaesthetics. The definitions of 'peri-operative' cardiac arrest often include the intra-operative period and extends from 60 min to 48 h after anaesthesia completion. However, the characteristics of cardiac arrests, care settings, and resuscitation quality may differ between intra-operative and early postoperative cardiac arrests.

OBJECTIVE

To compare the mortality rates between intraoperative and early postoperative cardiac arrests (<24 h) following anaesthesia for paediatric noncardiac surgery.

DESIGN

A retrospective cohort study.

SETTING

In a tertiary care centre in Thailand during 2014 to 2019, the peri-operative period was defined as from the beginning of anaesthesia care until 24 h after anaesthesia completion.

PATIENTS

Paediatric patients aged 0 to 17 years who underwent anaesthesia for noncardiac surgery.

MAIN OUTCOME MEASURES

Mortality rates.

RESULTS

A total of 42 776 anaesthetics were identified, with 63 PPOCAs and 23 deaths (36.5%). The incidence (95% confidence interval) of PPOCAs and mortality were 14.7 (11.5 to 18.8) and 5.4 (3.6 to 8.1) per 10 000 anaesthetics, respectively. Among 63 PPOCAs, 41 (65%) and 22 (35%) occurred during the intra-operative and postoperative periods, respectively. The median [min to max] time of postoperative cardiac arrest was 3.84 [0.05 to 19.47] h after anaesthesia completion. Mortalities (mortality rate) of postoperative cardiac arrest were significantly higher than that of intra-operative cardiac arrest at 14 (63.6%) vs. 9 (22.0%, P = 0.001). Multivariate analysis of risk factors for mortality included emergency status and duration of cardiopulmonary resuscitation with adjusted odds ratio 5.388 (95% confidence interval (1.031 to 28.160) and 1.067 (1.016 to 1.120).

CONCLUSIONS

Postoperative cardiac arrest resulted in a higher mortality rate than intra-operative cardiac arrest. A high level of care should be provided for at least 24 h after the completion of anaesthesia.

TRIAL REGISTRATION

None.

CLINICAL TRIAL NUMBER AND REGISTRY URL

NA.

Complications associated with removal of airway devices under deep anesthesia in children: an analysis of the Wake Up Safe database

Background

Previous studies examining removal of endotracheal tubes and supraglottic devices under deep anesthesia were underpowered to identify rare complications. This study sought to report all adverse events associated with this practice found in a large national database of pediatric anesthesia adverse events.

Methods

An extract of an adverse events database created by the Wake Up Safe database, a multi-institutional pediatric anesthesia quality improvement initiative, was performed for this study. It was screened to identify anesthetics with variables indicating removal of airway devices under deep anesthesia. Three anesthesiologists screened the data to identify events where this practice possibly contributed to the event. Event data was extracted and collated.

Results

One hundred two events met screening criteria and 66 met inclusion criteria. Two cardiac etiology events were identified, one of which resulted in the patient’s demise. The remaining 97% of events were respiratory in nature (64 events), including airway obstruction, laryngospasm, bronchospasm and aspiration. Some respiratory events consisted of multiple distinct events in series. Nineteen respiratory events resulted in cardiac arrest (29.7%) of which 15 (78.9%) were deemed preventable by local anesthesiologists performing independent review. Respiratory events resulted in intensive care unit admission (37.5%), prolonged intubation and temporary neurologic injury but no permanent harm. Provider and patient factors were root causes in most events. Upon investigation, areas for improvement identified included improving patient selection, ensuring monitoring, availability of intravenous access, and access to emergency drugs and equipment until emergence.

Conclusions

Serious adverse events have been associated with this practice, but no respiratory events were associated with long-term harm.

On-Hours Compared to Off-Hours Pediatric Extracorporeal Life Support Initiation in the United States Between 2009 and 2018-An Analysis of the Extracorporeal Life Support Organization Registry

We aimed to investigate whether there are differences in outcome for pediatric patients when extracorporeal life support (ECLS) is initiated on-hours compared with off-hours.

DESIGN

Retrospective cohort study.

SETTING

Ten-year period (2009-2018) in United States centers, from the Extracorporeal Life Support Organization registry.

PATIENTS

Pediatric (>30 d and <18 yr old) patients undergoing venovenous and venoarterial ECLS.

INTERVENTIONS

The primary predictor was on versus off-hours cannulation. On-hours were defined as 0700-1859 from Monday to Friday. Off-hours were defined as 1900-0659 from Monday to Thursday or 1900 Friday to 0659 Monday or any time during a United States national holiday. The primary outcome was inhospital mortality. The secondary outcomes were complications related to ECLS and length of hospital stay.

MEASUREMENTS AND MAIN RESULTS

In a cohort of 9,400 patients, 4,331 (46.1%) were cannulated on-hours and 5,069 (53.9%) off-hours. In the off-hours group, 2,220/5,069 patients died (44.0%) versus 1,894/4,331 (44.1%) in the on-hours group (p = 0.93). Hemorrhagic complications were lower in the off-hours group versus the on-hours group (hemorrhagic 18.4% vs 21.0%; p = 0.002). After adjusting for patient complexity and other confounders, there were no differences between the groups in mortality (odds ratio [OR], 0.95; 95% CI, 0.85-1.07; p = 0.41) or any complications (OR, 1.02; 95% CI, 0.89-1.17; p = 0.75).

CONCLUSIONS

Survival and complication rates are similar for pediatric patients when ECLS is initiated on-hours compared with off-hours. This finding suggests that, in aggregate, the current pediatric ECLS infrastructure in the United States provides adequate capabilities for the initiation of ECLS across all hours of the day.

Congenital Heart Defects in Patients with Classic Bladder Exstrophy: A Hitherto Neglected Association?

INTRODUCTION

 Classic bladder exstrophy (BE) is regarded as an isolated malformation without any further anomalies, but some studies have indicated a higher incidence of cardiac anomalies. This cross-sectional study is planned to evaluate the prevalence of congenital heart defects (CHDs) and the clinical relevance for patients with BE admitted for primary closure.

MATERIALS AND METHODS

 Patients were prospectively recruited between March 2012 and January 2019. Patients' profiles including demographic data, results of transthoracic echocardiography (TTE), as well as essential peri- and postoperative data were assessed.

RESULTS

 Thirty-nine (25 boys and 14 girls) patients with BE (median age 61 days) underwent delayed primary bladder closure. Thirty-seven (24 boys and 13 girls) patients had received TTE 1 day before surgery. CHD was detected in 7 (18.9%) out of the 39 patients, but no clinical differences between patients with and without CHD were observed peri- or postoperatively.

DISCUSSION AND CONCLUSION

 This prospective systematic evaluation shows an even higher rate of CHD in patients with BE than assumed previously. Although peri- and postoperative outcome did not differ between patients with and without CHD, we consider TTE an important additional method for ensuring a safe peri- and postoperative courses and a short- and long-term care for patients with CHD.

New European Resuscitation Council guidelines for pediatric life support and their implications for pediatric anesthesia: An educational article

In this educational article, we summarize the changes in the new European Resuscitation Council guidelines for Pediatric Life Support, emphasizing the most important aspects for the anesthesiologist. Among these are: the use of two-thumb-encircling technique for thorax compressions in infants, 10 ml/kg as the standard volume fluid bolus and ventilation after intubation at an age-dependent rate. Using a fictitious case, we present a point-by-point summary of the changes and briefly mention some of the evidence behind them, referring the reader to the full guidelines for further evidence. We also give a summary of the incidence, causes, challenges, treatment, and prognosis of pediatric cardiac arrest in the operating room.

Global mortality of children after perioperative cardiac arrest: A systematic review, meta-analysis, and meta-regression

Background

The body of evidence showed that perioperative cardiac arrest and mortality trends varied globally over time particularly in low and middle-income nations. However, the survival of children after cardiac arrest and its independent predictors are still uncertain and a topic of debate. This study was designed to investigate the mortality of children after a perioperative cardiac arrest based on a systematic review of published peer-reviewed literature.

Methods

A comprehensive search was conducted in PubMed/Medline; Science direct, CINHAL, and LILACS from December 2000 to August 2021. All observational studies reporting the rate of perioperative CA among children were included. The data were extracted with two independent authors in a customized format. The methodological quality of the included studies was evaluated using the Newcastle-Ottawa appraisal tool.

Results

A total of 397 articles were identified from different databases. Thirty-eight studies with 3.35 million participants were included. The meta-analysis revealed that the global incidence of perioperative cardiac arrest was 2.54(95% CI: 2.23 to 2.84) per 1000 anesthetics. The global incidence of perioperative mortality was 41.18 (95% CI: 35.68 to 46.68) per 1000 anesthetics.

Conclusion

The incidence of anesthesia-related pediatric cardiac arrest and mortality is persistently high in the last twenty years in low and middle-income countries. This probes an investment in continuous medical education of the perioperative staff and adhering with the international standard operating protocols for common procedures and critical situations.

Registration

This systematic review and meta-analysis is registered in the research registry (UIN: researchregistry6932).

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The incidence of anesthesia-related cardiac arrest and mortality is persistently high in low and middle-income countries.

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The review also showed that anesthesia-related cardiac arrest was very high among younger children with congenital heart disease.

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The overall perioperative cardiac arrest among children has decreased in the last 20 years in high-income countries.

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The Meta-analysis strongly recommends continuous medical education of the perioperative staff, and adherence to the international standard operating protocols.

Paediatric In-hospital cardiopulmonary resuscitation quality and outcomes in children with CHD during nights and weekends

BACKGROUND

Survival after paediatric in-hospital cardiac arrest is worse on nights and weekends without demonstration of disparity in cardiopulmonary resuscitation quality. It is unknown whether these findings differ in children with CHD. This study aimed to determine whether cardiopulmonary resuscitation quality might explain the hypothesised worse outcomes of children with CHD during nights and weekends.

METHODS

In-hospital cardiac arrest data collected by the Pediatric Resuscitation Quality Collaborative for children with CHD. Chest compression quality metrics and survival outcomes were compared between events that occurred during day versus night, and during weekday versus weekend using multivariable logistic regression.

RESULTS

We evaluated 3614 sixty-second epochs of chest compression data from 132 subjects between 2015 and 2020. There was no difference in chest compression quality metrics during day versus night or weekday versus weekend. Weekday versus weekend was associated with improved survival to hospital discharge (adjusted odds ratio 4.56 [1.29,16.11]; p = 0.02] and survival to hospital discharge with favourable neurological outcomes (adjusted odds ratio 6.35 [1.36,29.6]; p = 0.02), but no difference with rate of return of spontaneous circulation or return of circulation. There was no difference in outcomes for day versus night.

CONCLUSION

For children with CHD and in-hospital cardiac arrest, there was no difference in chest compression quality metrics by time of day or day of week. Although there was no difference in outcomes for events during days versus nights, there was improved survival to hospital discharge and survival to hospital discharge with favourable neurological outcome for events occurring on weekdays compared to weekends.

An Evaluation of Severe Anesthetic-Related Critical Incidents and Risks From the South African Paediatric Surgical Outcomes Study: A 14-Day Prospective, Observational Cohort Study of Pediatric Surgical Patients

BACKGROUND

Severe anesthetic-related critical incident (SARCI) monitoring is an essential component of safe, quality anesthetic care. Predominantly retrospective data from low- and middle-income countries (LMICs) report higher incidence but similar types of SARCI compared to high-income countries (HIC). The aim of our study was to describe the baseline incidence of SARCI in a middle-income country (MIC) and to identify associated risk for SARCI. We hypothesized a higher incidence but similar types of SARCI and risks compared to HICs.

METHODS

We performed a 14-day, prospective multicenter observational cohort study of pediatric patients (aged <16 years) undergoing surgery in government-funded hospitals in South Africa, a MIC, to determine perioperative outcomes. This analysis described the incidence and types of SARCI and associated perioperative cardiac arrests (POCAs). We used multivariable logistic regression analysis to identify risk factors independently associated with SARCI, including 7 a priori variables and additional candidate variables based on their univariable performance.

RESULTS

Two thousand and twenty-four patients were recruited from May 22 to August 22, 2017, at 43 hospitals. The mean age was 5.9 years (±standard deviation 4.2). A majority of patients during this 14-day period were American Society of Anesthesiologists (ASA) physical status I (66.4%) or presenting for minor surgery (54.9%). A specialist anesthesiologist managed 59% of cases. These patients were found to be significantly younger (P < .001) and had higher ASA physical status (P < .001). A total of 426 SARCI was documented in 322 of 2024 patients, an overall incidence of 15.9% (95% confidence interval [CI], 14.4-17.6). The most common event was respiratory (214 of 426; 50.2%) with an incidence of 8.5% (95% CI, 7.4-9.8). Six children (0.3%; 95% CI, 0.1-0.6) had a POCA, of whom 4 died in hospital. Risks independently associated with a SARCI were age (adjusted odds ratio [aOR] = 0.95; CI, 0.92-0.98; P = .004), increasing ASA physical status (aOR = 1.85, 1,74, and 2.73 for ASA II, ASA III, and ASA IV-V physical status, respectively), urgent/emergent surgery (aOR = 1.35, 95% CI, 1.02-1.78; P = .036), preoperative respiratory infection (aOR = 2.47, 95% CI, 1.64-3.73; P < .001), chronic respiratory comorbidity (aOR = 1.75, 95% CI, 1.10-2.79; P = .018), severity of surgery (intermediate surgery aOR = 1.84, 95% CI, 1.39-2.45; P < .001), and level of hospital (first-level hospitals aOR = 2.81, 95% CI, 1.60-4.93; P < .001).

CONCLUSIONS

The incidence of SARCI in South Africa was 3 times greater than in HICs, and an associated POCA was 10 times more common. The risk factors associated with SARCI may assist with targeted interventions to improve safety and to triage children to the optimal level of care.

Anesthesiologist-related factors associated with risk-adjusted pediatric anesthesia-related cardiopulmonary arrest: a retrospective two level analysis

BACKGROUND

Pediatric anesthesia-related cardiac arrest is an uncommon but catastrophic adverse event which has been, in a previous study, associated with anesthesiologist-related factors such as number of days per year providing pediatric anesthesia. We aimed to replicate this and assess other anesthesiologist-related risk factors for anesthesia-related cardiac arrest after adjusting for known underlying risk factors present in the case mix.

METHODS

We analyzed a large retrospectively collected patient cohort of anesthetics administered from 2006 to 2016 to children at a tertiary pediatric hospital. Three reviewers independently reviewed cardiac arrests and categorized whether they appeared to be related to anesthesia care. Anesthesiologist-related factors including academic rank, experience, recent case mix, and days per year delivering pediatric anesthesia were assessed for association with anesthesia-related cardiac arrest after adjustment for underlying case mix.

RESULTS

Cardiac arrest occurred in 240 of 109 775 anesthetics (incidence 22/10 000 anesthetics); 82 (7/10 000 anesthetics) were classified as anesthesia-related. In univariable analyses, anesthesia-related cardiac arrest was associated with age, (infants ≤180 days, p < .001) American Society of Anesthesiologists Physical Status, (>2, p < .001) American Society of Anesthesiologists Physical Status Emergency, (p = .0035) cardiac surgery, (p < .001) operating room location, (p = .0066) and resident/fellow supervision, (p = .009) but none of the anesthesiologist factors. Even after adjusting for age and American Society of Anesthesiologist Status, none of the anesthesiologist factors were associated with anesthesia-related cardiac arrest.

CONCLUSIONS

Case mix explained all associations between higher risk of pediatric anesthesia-related cardiac arrest and anesthesiologist-related variables at our institution.

Incidence, characteristics and risk factors for perioperative cardiac arrest and 30-day-mortality in preterm infants requiring non-cardiac surgery

STUDY OBJECTIVE

To determine 30-day-mortality, incidence and characteristics of perioperative cardiac arrest as well as the respective independent risk factors in preterm infants undergoing non-cardiac surgery.

DESIGN

Retrospective observational Follow-up-study.

SETTING

Bielefeld University Hospital, a German tertiary care hospital.

PATIENTS

Population of 229 preterm infants (age < 37th gestational week at the time of surgery) who underwent non-cardiac surgery between 01/2008-12/2018.

MEASUREMENTS

Primary endpoint was overall 30-day-mortality. Secondary endpoints were the incidence of perioperative cardiac arrest and identification of independent risk factors. We performed univariate and multivariate analyses and calculated odds ratios (OR) for risk factors associated with these endpoints.

MAIN RESULTS

30-day-mortality was 10.9% and perioperative mortality 0.9%. Univariate risk factors for 30-day-mortality were perioperative cardiac arrest (OR,12.5;95%CI,3.1 to 50.3), comorbidities of lungs (OR,3.7;95%CI,1.2 to 11.3) and gastrointestinal tract (OR,3.5;95%CI,1.3 to 9.6); sepsis (OR,3.6;95%CI,1.4 to 9.5); surgery between 22:01-7:00 (OR,7.3;95%CI,2.4 to 21.7); emergency (OR,4.5;95%CI,1.6 to 12.4); pre-existing catecholamine therapy (OR,5.0;95%CI,2.1 to 11.9). Multivariate logistic regression indicated that perioperative cardiac arrest (OR,13.9;95%CI,2.7 to 71.3), low body weight (weight < 1000 g: OR,26.0;95%CI,3.2 to 212; 1000-1499 g: OR,10.3; 95%CI,1.1 to 94.9 compared to weight > 2000 g), and time of surgery (OR,5.9;95%CI,1.6 to 21.3) for 22:01-7:00 compared to 7:01-15:00) were the major independent risk factors of mortality. Incidence of perioperative cardiac arrests was 3.9% (9 of 229;95%CI,1.8 to 7.3). Univariate risk factors were congenital anomalies of the airways (OR,4.7;95%CI,1.2 to 20.3), lungs (OR,4.7;95%CI,1.2 to 20.3) and heart (OR,8.0;95%CI,2 to 32.2), pre-existing catecholamine therapy (OR,59.5;95%CI,3.4 to 1039), specifically, continuous infusions of epinephrine (OR,432;95%CI,43.2 to 4318).

CONCLUSIONS

30-day-mortality and the incidence of perioperative cardiac arrest of preterms undergoing non-cardiac surgery were higher than previously reported. The identified independent risk factors may improve interdisciplinary perioperative risk assessment, optimal preoperative stabilization and scheduling of optimal surgical timing.

Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE)

BACKGROUND

Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown.

METHODS

This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events.

RESULTS

Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO₂ <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7).

CONCLUSIONS

Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants.

CLINICAL TRIAL REGISTRATION

NCT02350348.

Perioperative anaphylaxis in children: A report from the Wake-Up Safe collaborative

BACKGROUND

Anaphylactic reactions to antigens in the perioperative environment are uncommon, but they have a potential to lead to serious morbidity and/or mortality. The incidence of anaphylactic reactions is 1:37 000 pediatric anesthetics, and substantially less than the 1:10 000 to 1:20 000 incidence in the adult population. Neuromuscular blocking agents, latex, and antibiotics are the most frequently cited triggers. To date, there is no comprehensive report on perioperative anaphylactic reactions in children in the United States. Using the Wake-up Safe database, we examined the incidence and consequences of reported perioperative anaphylaxis events.

METHODS

We reviewed the Wake-up Safe database from 2010 to 2017 and identified all reported instances of anaphylaxis. The triggering agent, timing, and location of the registered event, severity of patient harm, and preventability were identified. Narrative review of free-text comments entered by reporting centers was performed to determine presenting symptoms, and interventions required. Type of case was identified from procedure codes provided in mandatory fields.

RESULTS

Among 2 261 749 cases reported to the Wake-up Safe database during the study period, perioperative anaphylactic reactions occurred in 1:36 479 (0.003%). Antibiotics, neuromuscular blocking agents, and opioid analgesics were the main triggers. Forty-nine cases (79%) occurred in the operating room, and 13 cases (21%) occurred in off-site locations. Seven (11%) patients required cardiopulmonary resuscitation following the onset of symptoms. Thirty-five (57%) patients were treated with epinephrine or epinephrine plus other medications, whereas 5% were managed only with phenylephrine. Most cases (97%) required escalation of care after the event. Regarding case preventability, 91% of cases were marked as either "likely could not have been prevented" or "almost certainly could not have been prevented."

CONCLUSION

The estimated incidence of anaphylaxis and inciting agents among the pediatric population in this study were consistent with the most recent published studies outside of the United States; however, new findings included need for cardiopulmonary resuscitation in 11% of cases, and estimated fatality of 1.6%. The management of perioperative anaphylaxis could be improved for some cases as epinephrine was not administered, or its administration was delayed. Fewer than half of reported cases had additional investigation to formally identify the responsible agent.

Pediatric anesthesia training to early career stage: Opportunities for firm foundations

Attaining professional contentment can be challenging for many. Academic success, psychosocial support, and the confidence to provide excellent clinical care at the workplace are key pillars that can help build a sense of meaning in a career. The role of mentorship in facilitating these key pillars at different stages of pediatric anesthesia training and new independent practice is instrumental. For mentees aspiring for a career in pediatric anesthesia, there are several points of focus. Mentees should seek out mentors early in training, build on these relationships, and explore opportunities for peer mentorship as they advance in their career. For mentors, introducing mentees to the clinical and academic aspects of pediatric anesthesia and setting the foundation for the mentee to advance in their career can be both gratifying and stimulating. In this article, we explore the development and progression of a mentor-mentee relationship through training to the early career stage and its role in developing a meaningful career in pediatric anesthesia.

Best practice & research clinical anesthesiology: Safety and quality in perioperative anesthesia care. Update on safety in pediatric anesthesia

Pediatric anesthesia is large part of anesthesia clinical practice. Children, parents and anesthesiologists fear anesthesia because of the risk of acute morbidity and mortality. Modern anesthesia in otherwise healthy children above 1 year of age in developed countries has become very safe due to recent advance in pharmacology, intensive education, and training as well as centralization of care. In contrast, anesthesia in these children in low-income countries is associated with a high risk of mortality due to lack of basic resources and adequate training of health care providers. Anesthesia for neonates and toddlers is associated with significant morbidity and mortality. Anesthesia-related (near) critical incidents occur in 5% of anesthetic procedures and are largely dependent on the skills and up-to-date knowledge of the whole perioperative team in the specific needs for children. An investment in continuous medical education of the perioperative staff is required and international standard operating protocols for common procedures and critical situations should be defined.

Hot Topics in Safety for Pediatric Anesthesia

Anesthesiology is one of the leading medical specialties in patient safety. Pediatric anesthesiology is inherently higher risk than adult anesthesia due to differences in the physiology in children. In this review, we aimed to describe the highest yield safety topics for pediatric anesthesia and efforts to ameliorate risk. Conclusions: Pediatric anesthesiology has made great strides in patient perioperative safety with initiatives including the creation of a specialty society, quality and safety committees, large multi-institutional research efforts, and quality improvement initiatives. Common pediatric peri-operative events are now monitored with multi-institution and organization collaborative efforts, such as Wake Up Safe.

Complications Associated With the Anesthesia Transport of Pediatric Patients: An Analysis of the Wake Up Safe Database

BACKGROUND

Transporting patients under anesthesia care incurs numerous potential risks, especially for those with critical illness. The purpose of this study is to identify and report all pediatric anesthesia transport-associated adverse events from a preexisting database of perioperative adverse events.

METHODS

An extract of the Wake Up Safe database was obtained on December 14, 2017, and screened for anesthesia transport-associated complications. This was defined as events occurring during or immediately after transport or movement of a pediatric patient during or in proximity to their care by anesthesiologists, including repositioning and transfer to recovery or an inpatient unit, if the cause was noted to be associated with anesthesia or handover. Events were excluded if the narrative clearly states that an event was ongoing and not impacted by anesthesia transport, such as a patient who develops cardiac arrest that then requires emergent transfer to the operating room. The search methodology included specific existing data elements that indicate transport of the patient, handover or intensive care status preoperatively as well as a free-text search of the narrative for fragments of words indicating movement. Screened events were reviewed by 3 anesthesiologists for inclusion, and all data elements were extracted for analysis.

RESULTS

Of 2971 events in the database extract, 63.8% met screening criteria and 5.0% (148 events) were related to transport. Events were primarily respiratory in nature. Nearly 40% of all reported events occurred in infants age ≤6 months. A total of 59.7% of events were at least somewhat preventable and 36.4% were associated with patient harm, usually temporary. Of the 86 reported cardiac arrests, 50 (58.1%) had respiratory causes, of which 74% related to anesthesia or perioperative team factors. Respiratory events occurred at all stages of care, with 21.4% during preoperative transport and 75.5% postoperatively. Ninety-three percent of unplanned extubations occurred in patients 6 months and younger. Ten medication events were noted, 2 of which resulted in cardiac arrest. Root causes in all events related primarily to provider and patient factors, with occasional references to verbal miscommunication.

CONCLUSIONS

Five percent of reported pediatric anesthesia adverse events are associated with transport. Learning points highlight the risk of emergence from anesthesia during transport to recovery or intensive care unit (ICU). ICU patients undergoing anesthesia transport face risks relating to transitions in providers, equipment, sedation, and physical positioning. Sedation and neuromuscular blockade may be necessary for transport in some patients but has been associated with adverse events in others.

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.

Extubation and the Risks of Coughing and Laryngospasm in the Era of Coronavirus Disease-19 (COVID-19)

The coronavirus disease-19 (COVID-19) pandemic has prompted new interest among anesthesiologists and intensivists in controlling coughing and expectoration of potentially infectious aerosolized secretions during intubation and extubation. However, the fear of provoking laryngospasm may cause avoidance of deep or sedated extubation techniques which could reduce coughing and infection risk. This fear may be alleviated with clear understanding of the mechanisms and effective management of post-extubation airway obstruction including laryngospasm. We review the dynamic function of the larynx from the vantage point of head-and-neck surgery, highlighting two key concepts:

1. The larynx is a complex organ that may occlude reflexively at levels other than the true vocal folds;

2. The widely held belief that positive-pressure ventilation by mask can “break” laryngospasm is not supported by the otorhinolaryngology literature.

We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes.

Description and function of a difficult airway service

The goal of the Pediatric Difficult Airway Service (DAS) is to improve the care of children with airway abnormalities primarily through identification of children at risk for failed airway management. The airway service encourages early recognition and provides consultation, a plan for airway management, expertise in airway management, and follow-up care for children who have a difficult airway. The service has improved the education of healthcare professionals and heightened awareness about the consequences of failed airway management.

Neonatal intensive care unit patients recovering in the post anesthesia care unit: An observational analysis of postextubation complications

BACKGROUND

Neonatal patients are at higher risk in the perioperative period than older infants and children. Extubation as an early goal for noenatal intensive care unit patients presenting for surgery is undergoing a renaissance period, and an exploration of adverse events following selection for extubation immediately after general anesthesia has not specifically been undertaken in this population.

AIMS

The objective of this study is to determine the adverse events most commonly encountered in neonatal intensive care unit patients recovering from anesthesia in the post anesthesia care unit, quantify the risk of event occurrence, and identify risk factors that may increase the risk of postoperative adverse events.

METHODS

All neonatal intensive care unit patients presenting to the operating room 6/1/2014-5/31/2018 who recovered in the  post anesthesia care unit were included for analysis. Univariate analyses were conducted utilizing the Wilcoxon rank-sum test or Fisher exact test. Due to the low event rate, a small-sample generalized estimating equation model was created with a major event composite as the outcome and explanatory variables with P values < .1 on univariate analysis. Statistically significant continuous variables were then dichotomized based on Youden index.

RESULTS

There were 707 operative cases in 607 patients. There were 81 total events recorded, and 64/81 were considered to be major events; all of which were respiratory. The risk of any postoperative event was 11.5%, major respiratory event requiring intervention by a nurse or provider was 9.1%, and reintubation was 0.8%. Birth weight < 1.58 kg (OR 3.71; 95% CI 2.11-6.53; P < .001) and postmenstrual age at surgery <41 weeks (OR 3.20; 95% CI 1.54-6.63; P < .001) were strongly associated with an increased risk of a major postoperative respiratory event.

CONCLUSION

The most important factors associated with major events in the post anesthesia care unit following extubation of neonatal intensive care unit patients were birth weight < 1.58 kg and postmenstrual age at surgery < 41 weeks. A patient with both features has a 7-fold increase in the odds of a major respiratory event in the post anesthesia care unit. Careful consideration of the postoperative ventilation and monitoring strategy must be given to patients with low birth weight (<1.58 kg) or who are <41 weeks postmenstrual age at the time of surgery.

Development of a Multidisciplinary Pediatric Airway Program: An Institutional Experience

Rapid response teams have become necessary components of patient care within the hospital community, including for airway management. Pediatric patients with an increased risk of having a difficult airway emergency can often be predicted on the basis of clinical scenarios and medical history. This predictability has led to the creation of airway consultation services designed to develop airway management plans for patients experiencing respiratory distress and who are at risk for having a difficult airway requiring advanced airway management. In addition, evolving technology has facilitated airway management outside of the operating suite. Training and continuing education on the use of these tools for airway management is imperative for clinicians responding to airway emergencies. We describe the comprehensive multidisciplinary, multicomponent Pediatric Difficult Airway Program we created that addresses each component identified above: the Pediatric Difficult Airway Response Team (PDART), the Pediatric Difficult Airway Consult Service, and the pediatric educational airway program. Approximately 41% of our PDART emergency calls occurred in the evening hours, requiring a specialized team ready to respond throughout the day and night. A multitude of devices were used during the calls, obviating the need for formal education and hands-on experience with these devices. Lastly, we observed that the majority of PDART calls occurred in patients who either were previously designated as having a difficult airway and/or had anatomic variations that suggest challenges during airway management. By instituting the Pediatric Difficult Airway Consult Service, we have decreased emergent Difficult Airway Response Team calls with the ultimate goal of first-attempt intubation success.

Severe outcomes of pediatric perioperative adverse events occurring in operating rooms compared to off-site anesthetizing locations in the Wake Up Safe Database

BACKGROUND

Anesthesia services are frequently provided outside of the traditional operating room environment for children. It is unclear if adverse events which occur in off-site anesthetizing locations result in more severe outcomes compared to events in traditional operating rooms.

AIM

We used a multi-institutional registry of pediatric patients to compare outcomes of perioperative adverse events between location types.

METHODS

De-identified data from 24 pediatric tertiary care hospitals participating in the Wake Up Safe registry during 2010-2015 were analyzed. Peri-procedural adverse events occurring in operating rooms or off-site locations were included. The primary outcome was whether the adverse event was severe, defined as requiring escalation of care or resulting in temporary or significant harm. Multivariable logistic regression was used to compare location type (operating room vs. off-site) and the likelihood of a severe outcome among reported events.

RESULTS

There were 1594 adverse events, of which 362 were associated with off-site anesthetizing locations. In multivariable logistic regression, off-site location was associated with greater odds of severe adverse event outcome (adjusted odds ratio, 1.31; 95% confidence interval: 1.01, 1.69; P = 0.044). Comparing adverse events in cardiac catheterization suites to events in operating rooms confirmed higher odds of severe outcome in the former group (adjusted odds ratio = 1.48; 95% confidence interval: 1.05, 2.08; P = 0.025), while this difference was not found for other off-site locations.

CONCLUSION

Multivariable analysis of a large registry revealed a greater likelihood of severe outcome for adverse events occurring in cardiac catheterization suites (but not other out of the OR sites), compared to adverse events occurring in the operating room. Additional prospective studies are needed which better control for patient and environmental characteristics and their effect on severe outcomes after anesthesia.