Pediatric anesthesia after APRICOT (Anaesthesia PRactice In Children Observational Trial): who should do it?

Algorithmic prediction of anaesthesia manpower quantity needs: A multicentre study

BACKGROUND

A shortage of anaesthetists affects health system globally. This is a study on task-force to develop a predictive model for the appropriate number of anaesthetic providers (Y).

METHODS

A cross-sectional study was performed with randomisation from every health service region across Thailand. The decision-making criteria for manpower needed were written and provided guidance. The number of personnel was calculated from the sum of total time spent by all anaesthetic providers divided by duration of the service. Linear regression analysis was applied.

RESULTS

In total 3774 patients were included from 18 hospitals. The factors that affect the anaesthetic providers' allocation needs were included in the predictive model, calculated as Y = 3.53 + [0.56 (standard centre) + 0.36 (advanced centre) + 1.03 (specialty centre)] + 0.07 (American Society of Anesthesiologists physical status IV and V) + 0.61 (advanced anaesthetic medication) + [0.61 (monitored anaesthesia care) + 0.17 (general anaesthesia)] - [0.27 (pre-anaesthetic duration within 31-60 minutes) + (0.61 (over 60 minutes)] - [0.85 (anaesthetic duration within 31-60 minutes) + 1.04 (within 61-120 minutes) + 1.32 (over 120 minutes)] - [0.16 (post-anaesthetic duration within 31-60 minutes) + 0.45 (within 61-90 minutes) + 0.74 (over 90 minutes)].

CONCLUSION

The anaesthesia manpower algorithm developed during this study can be used to calculate the number of anaesthetists per population to maintain health services.

Beyond mortality: definitions and benchmarks of outcome standards in paediatric anaesthesiology

PURPOSE OF REVIEW

The aim of this study was to review the evolution of safety and outcomes in paediatric anaesthesia, identify gaps in quality and how these gaps may influence outcomes, and to propose a plan to address these challenges through the creation of universal outcome standards and a paediatric anaesthesia designation programme.

RECENT FINDINGS

Tremendous advancements in the quality and safety of paediatric anaesthesia care have occurred since the 1950 s, resulting in a near absence of documented mortality in children undergoing general anaesthesia. However, the majority of data we have on paediatric anaesthesia outcomes come from specialized academic institutions, whereas most children are being anaesthetized outside of free-standing children's hospitals.

SUMMARY

Although the literature supports dramatic improvements in patient safety during anaesthesia, there are still gaps, particularly in where a child receives anaesthesia care and in quality outcomes beyond mortality. Our goal is to increase equity in care, create standardized outcome measures in paediatric anaesthesia and build a verification system to ensure that these targets are accomplished. The time has come to benchmark paediatric anaesthesia care and increase quality received by all children with universal measures that go beyond simply mortality.

Perioperative critical events and morbidity associated with anesthesia in early life: Subgroup analysis of United Kingdom participation in the NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective multicenter observational study

BACKGROUND

The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective observational study reported critical events requiring intervention during 35.2% of 6542 anesthetic episodes in 5609 infants up to 60 weeks postmenstrual age. The United Kingdom (UK) was one of 31 participating countries.

METHODS

Subgroup analysis of UK NECTARINE cases (12.8% of cohort) to identify perioperative critical events that triggered medical interventions. Secondary aims were to describe UK practice, identify factors more commonly associated with critical events, and compare 30-day morbidity and mortality between participating UK and nonUK centers.

RESULTS

Seventeen UK centers recruited 722 patients (68.7% male, 36.1% born preterm, and 48.1% congenital anomalies) undergoing anesthesia for 876 surgical or diagnostic procedures at 25-60 weeks postmenstrual age. Repeat anesthesia/surgery was common: 17.6% patients prior to and 14.4% during the recruitment period. Perioperative critical events triggered interventions in 300/876 (34.3%) cases. Cardiovascular instability (16.9% of cases) and/or reduced oxygenation (11.4%) were more common in younger patients and those with co-morbidities or requiring preoperative intensive support. A higher proportion of UK than nonUK cases were graded as ASA-Physical Status scores >2 or requiring urgent or emergency procedures, and 39% required postoperative intensive care. Thirty-day morbidity (complications in 17.2%) and mortality (8/715, 1.1%) did not differ from nonUK participants.

CONCLUSIONS

Perioperative critical events and co-morbidities are common in neonates and young infants. Thirty-day morbidity and mortality data did not demonstrate national differences in outcome. Identifying factors associated with increased risk informs preoperative assessment, resource allocation, and discussions between clinicians and families.

After nectarine: how should we provide anesthesia for neonates?

PURPOSE OF REVIEW

Neonates have a high risk of perioperative morbidity and mortality. The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) investigated the anesthesia practice, complications and perioperative morbidity and mortality in neonates and infants <60 weeks post menstrual age requiring anesthesia across 165 European hospitals. The goal of this review is to highlight recent publications in the context of the NECTARINE findings and subsequent changes in clinical practice.

RECENT FINDINGS

A perioperative triad of hypoxia, anemia, and hypotension is associated with an increased overall mortality at 30 days. Hypoxia is frequent at induction and during maintenance of anesthesia and is commonly addressed once oxygen saturation fall below 85%.Blood transfusion practices vary widely variable among anesthesiologists and blood pressure is only a poor surrogate of tissue perfusion. Newer technologies, whereas acknowledging important limitations, may represent the currently best tools available to monitor tissue perfusion. Harmonization of pediatric anesthesia education and training, development of evidence-based practice guidelines, and provision of centralized care appear to be paramount as well as pediatric center referrals and international data collection networks.

SUMMARY

The NECTARINE provided new insights into European neonatal anesthesia practice and subsequent morbidity and mortality.Maintenance of physiological homeostasis, optimization of oxygen delivery by avoiding the triad of hypotension, hypoxia, and anemia are the main factors to reduce morbidity and mortality. Underlying and preexisting conditions such as prematurity, congenital abnormalities carry high risk of morbidity and mortality and require specialist care in pediatric referral centers.

A pragmatic approach to quality improvement in pediatric anesthesia

PURPOSE OF REVIEW

The concept of quality improvement (QI) is well implemented in pediatric anesthesia. Conductance, reporting and publishing of QI projects and -results is well described and promoted. However, the perception of quality might differ between stakeholders and beneficiaries. Based on measures of quality as perceived by healthcare professionals and pediatric patients, a pragmatic approach to choosing the relevant quality measure is suggested.

RECENT FINDINGS

Design of QI projects is often motivated by an incentive to avoid errors and adverse events, and with an overall aim to reduce morbidity and mortality. From a patient- and parent point of view, avoidance of perioperative stress and anxiety might be a priority measure of quality.

SUMMARY

In an attempt to embrace both perspectives of quality in pediatric anesthesia care, it is suggested to choose quality items for improvement based on patient safety, professional excellency and benignancy. By following this approach, QI is expected to remain relevant to both healthcare professionals and patients.

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.

Epidemiology and incidence of severe respiratory critical events in ear, nose and throat surgery in children in Europe: A prospective multicentre observational study

BACKGROUND

Ear, nose and throat (ENT) surgery, the most frequently performed surgical procedure in children, is a strong predictor for peri-operative respiratory complications. However, there is no clear information about peri-operative respiratory severe critical events (SCEs) associated with anaesthesia management of ENT children in Europe.

OBJECTIVE

To characterise the epidemiology and incidence of respiratory SCEs during and following ENT surgery in Europe and to identify the risk factors for their occurrence.

DESIGN

A secondary analysis of the Anaesthesia PRactice In Children Observational Trial, a prospective observational multicentre cohort trial.

SETTING

The study included 261 centres across 33 European countries and took place over a consecutive 2-week recruitment period between April 2014 and January 2015.

PATIENTS

We extracted data from 5592 ENT surgical procedures that were performed on 5572 children aged 6.0 (3.6) years (mean (SD)) from the surgical database and compared these with data from 15 952 non-ENT surgical children aged 6.7 (4.8) years.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of respiratory SCEs (laryngospasm, bronchospasm and new onset of postoperative stridor). Secondary outcomes were the differences in epidemiology between ENT children and non-ENT surgical children and the risk factors for the occurrence of respiratory SCEs.

RESULTS

The incidence (95% confidence interval) of any respiratory SCE (laryngospasm, bronchospasm and postoperative stridor) was 3.93% (3.46 to 4.48) and was significantly higher than that observed in non-ENT surgical children [2.61% (2.37 to 2.87)], with a relative risk of 1.51 (1.28 to 1.77), P less than 0.0001. Younger age (14% decrease in critical events by increasing year, P < 0.0001), history of snoring, recent upper respiratory tract infection and recent wheezing increased the risk of suffering a SCE by over two-fold (P < 0.0001). There was also some evidence for a positive association with age below 4.6 years and lower surgical volume thresholds (<20 cases/2 weeks).

CONCLUSION

The results of this study provide additional evidence for strong associations between risk factors and respiratory SCEs in children having ENT surgery. These observations may facilitate the implementation of good clinical practice recommendations for ENT patients in Europe.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT01878760.

Risk associated with anesthesia for noncardiac surgery in children with congenital heart disease

Database analysis has indicated that perioperative cardiac arrest occurs with increased frequency in children with congenital heart disease. Several case series and large datasets from ACS NSQIP have identified subgroups at the highest risk. Consistently, patients with single ventricle physiology (especially prior to cavopulmonary anastomosis), severe/supra-systemic pulmonary hypertension, complex lesions, and cardiomyopathy with significantly reduced ventricular function have been shown to be at increased risk for adverse events. Based on these results, algorithms for assessing risk have been proposed. How hospitals and health care systems apply these guidelines to provide safe care for these challenging patient groups requires the application of modern quality improvement techniques. Each institution should develop a system which reflects local expertise and resources.