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Schifino Wolmeister A, Hansen TG, Engelhardt T. Challenges of organizing pediatric anesthesia in low and middle-income countries. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844525. [PMID: 38906364 PMCID: PMC11276913 DOI: 10.1016/j.bjane.2024.844525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Affiliation(s)
- Anelise Schifino Wolmeister
- Montreal Children's Hospital, Department of Anesthesia, Montreal, Canada; Hospital de Clínicas de Porto Alegre, Departamento de Anestesia e Medicina Perioperatória, Porto Alegre, RS, Brazil.
| | - Tom G Hansen
- Akershus University Hospital, Department of Anesthesia & Intensive Care, Lørenskog, Norway; University of Oslo, Institute of Clinical Medicine, Oslo, Norway
| | - Thomas Engelhardt
- Montreal Children's Hospital, Department of Anesthesia, Montreal, Canada
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Tiradentes TAA, Einav S, Braz JRC, Nunes-Nogueira VS, Betini M, Corrente JE, Braz MG, Braz LG. Global anaesthesia-related cardiac arrest rates in children: a systematic review and meta-analysis. Br J Anaesth 2023; 131:901-913. [PMID: 37743151 DOI: 10.1016/j.bja.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 09/26/2023] Open
Abstract
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.
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Affiliation(s)
- Teofilo Augusto A Tiradentes
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil
| | - Sharon Einav
- General Intensive Care Unit of the Shaare Zedek Medical Centre, Jerusalem, Israel; Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Jose R C Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil
| | - Vania S Nunes-Nogueira
- Department of Internal Medicine, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil
| | - Marluci Betini
- Technical Division of Library and Documentation, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil
| | - Jose E Corrente
- Department of Biostatistics, Institute of Biosciences, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil
| | - Mariana G Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil
| | - Leandro G Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Botucatu, Sao Paulo, Brazil.
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Hansen TG, Vieri J, Børke WB, Castellheim AG. Outcome following anaesthesia in infancy in the Nordic countries: Subgroup analysis of the NECTARINE study. Acta Anaesthesiol Scand 2023; 67:714-723. [PMID: 36918742 DOI: 10.1111/aas.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION The neonate and children audit of anaesthesia practice in Europe (NECTARINE) prospective observational study reported an incidence of 35.2% of critical events requiring intervention during 6542 anaesthetics in 5609 infants up to 60 weeks postmenstrual age (PMA) from 165 centres in 31 European countries. METHODS Sub-analysis of the cohort from the Nordic countries (8% of the entire cohort) was conducted. Secondary aims were to describe the Nordic countries' anaesthetic practices and compare morbidity and mortality with the overall European cohort. RESULTS Eleven Nordic centres recruited 447 infants (66% males, 37.3% born preterm and 45% had congenital anomalies) undergoing anaesthesia for 530 surgical or non-surgical procedures at 25-60 weeks PMA. Perioperative critical events triggered interventions in 228/530 (43%) cases. Hypotension (12.6%) or hypoxaemia (11.7%) were more common in younger patients and those with co-morbidities. Hypo/hypercapnia occurred in 1.5%/4.7% of cases. More than two attempts for intubation were required in 13 (2.9%) infants (max three attempts). Distribution of ASA-Physical Status Scores was similar to the total European cohort (40% was ASA > 2). A total of 236/530 (44.5%) patients were admitted to the postoperative intensive care unit. Thirty-day morbidity (complications in 87/447 = 19.5%) and mortality (8/447, 1.8%) did not differ from the overall European cohort. Hospital re-admissions were significant up to 90 days (98/447 = 21.9%). CONCLUSIONS In Nordic countries, anaesthesia in young infant children is resource-demanding, and perioperative critical events and co-morbidities are common. Thirty-day morbidity and mortality data in the Nordic countries did not differ from the overall European cohort.
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Affiliation(s)
- Tom G Hansen
- Department of Anaesthesiology and Intensive Care - Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Jenny Vieri
- Department of Prehospital Emergency Care, Pain Management and Anaesthesiology, Tampere University Hospital, Tampere, Finland
| | - Wenche Bakken Børke
- Division of Emergencies and Critical Care Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Albert Gyllencreutz Castellheim
- Department of Anaesthesiology and Intensive Care Medicine, Queen Silvia Children Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Abstract
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.
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Abstract
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.
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Cardiac arrest during endotracheal intubation of children with systolic dysfunction. Cardiol Young 2022; 33:532-538. [PMID: 35504840 DOI: 10.1017/s1047951122001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This multicenter study aimed to describe peri-intubation cardiac arrest in paediatric cardiac patients with significant (moderate or severe) systolic dysfunction of the systemic ventricle. Intubation data were collected from 4 paediatric cardiac ICUs in the United States (January 2015 - December 2017). Clinician practices during intubation of patients with significant dysfunction were compared to practices during intubation of patients without significant systolic dysfunction. There were 67 intubations in patients with significant systolic dysfunction. Peri-intubation cardiac arrest rate in this population was 14.9% (10/67); peri-intubation mortality was 3%. Majority (6/10; 60%) of the cardiac arrests were classified as pulseless electrical activity. Patients with cardiac arrest upon intubation had a higher serum lactate and lower serum pH than patients without peri-intubation cardiac arrest in the significant systolic dysfunction group.In comparing cardiac ICU patients with significant systolic dysfunction (n = 67) to patients from the same time period with normal ventricular function or mild dysfunction (n = 183), clinicians were less likely to use midazolam (11.9% versus 25.1%; p = 0.03) and more likely to use etomidate (16.4% versus 4.4%; p = 0.002) for intubation. Use of other sedative agents, video laryngoscopy, atropine, inotrope initiation, and consultation of an anaesthesiologist for intubation were not statistically different between the groups.This is the first study to describe the rate of and risk factors for peri-intubation cardiac arrest in paediatric cardiac ICU patients with systolic dysfunction. There was a higher peri-intubation cardiac arrest rate compared to published rates in critically ill children with heart disease and compared to children with significant systolic dysfunction undergoing elective general anaesthesia.
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Risk Factors for Peri-Intubation Cardiac Arrest in Pediatric Cardiac Intensive Care Patients: A Multicenter Study. Pediatr Crit Care Med 2020; 21:e1126-e1133. [PMID: 32740187 DOI: 10.1097/pcc.0000000000002472] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Endotracheal intubation is associated with hemodynamic adverse events, including cardiac arrest, especially in patients with cardiac disease. There are only a few studies that have evaluated the rate of and risk factors for endotracheal intubation hemodynamic complications in critically ill pediatric patients. Although some of these studies have assessed hemodynamic complications during intubation in pediatric cardiac patients, the frequency of and risk factors for peri-intubation cardiac arrest have not been adequately described in high acuity cardiac patients. This study aims to describe the frequency of and risk factors for peri-intubation cardiac arrest in critically ill pediatric cardiac patients admitted to specialized cardiac ICUs. DESIGN Multicenter retrospective cohort study. SETTING Three pediatric cardiac ICUs in the United States. PATIENTS Critically ill pediatric patients with congenital or acquired heart disease requiring endotracheal intubation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Endotracheal intubations performed in three cardiac ICUs between January 2015 and December 2017 were reviewed. Clinical variables-including data on patients, clinical providers, and procedure-were evaluated for their association with peri-intubation cardiac arrest. There was a total of 186 intubation events studied, occurring in 151 individual (index) patients. The rates of peri-intubation cardiac arrest and peri-intubation mortality in this cohort were 7% and 1.6%, respectively. Among those patients with moderate or severe systolic dysfunction of the systemic ventricle, peri-intubation cardiac arrest rate was 20.7%. Statistically significant risk factors for peri-intubation cardiac arrest included: significant systolic dysfunction of the systemic ventricle, pre-intubation hypotension, pre-intubation lactate elevation, lower pre-intubation pH, and documented oxygen desaturations (> 10%) during intubation procedure. CONCLUSIONS Our most significant finding was a peri-intubation cardiac arrest rate which was much higher than previously published rates for both cardiac and noncardiac children who underwent endotracheal intubation in ICUs. Peri-intubation mortality was also high in our cohort. Regarding risk factors for peri-intubation arrest, significant systolic dysfunction of the systemic ventricle was strongly associated with cardiac arrest in this cohort.
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Clebone A, Watkins SC, Tung A. The timing of cognitive aid access during simulated pediatric intraoperative critical events. Paediatr Anaesth 2020; 30:676-682. [PMID: 32271972 DOI: 10.1111/pan.13868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/18/2020] [Accepted: 03/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Many cognitive aids are formatted in a step-by-step fashion with the intent that the aid will be accessed at the beginning of a critical event and that key behaviors will be performed in sequence. AIMS We hypothesized that, during simulated pediatric intraoperative critical events, anesthesia clinicians may not use cognitive aids immediately after the onset of a critical event but instead access the aid only after first performing several key behaviors. MATERIALS AND METHODS This manuscript is a re-analysis of previously published simulation data. The original study involved 89 clinicians participating in 143 pediatric intraoperative events divided into 6 types: arrhythmia, venous air embolus, hypoxemia, malignant hyperthermia, hypotension, and supraventricular tachycardia. For each trial involving cognitive aid use, we measured the time from event trigger to cognitive aid use, and the number and type of key behaviors performed by simulation participants prior to cognitive aid access. RESULTS Cognitive aid use was sought in 66 of 93 trials where it was available. Sufficient data for this analysis were available in 65 trials. The average time from event trigger to first cognitive aid use was 258 seconds. In 62/65 trials (95%), the cognitive aid was accessed after at least one key behavior had already been performed. The time from event trigger to cognitive aid use varied by type of scenario (P = .03, df 5, adjusted H 12.78), with the shortest time for "supraventricular tachycardia" (90 [66,156] seconds (median [IQR]) and the longest time for "hypoxemia" (354 [192,492] seconds). CONCLUSION In simulated critical events, anesthesia residents and student nurse anesthetists often consulted a cognitive aid only after first performing at least some key behaviors. Incorporating the possibility of delayed access into critical event cognitive aid design may facilitate the effectiveness of that aid.
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Affiliation(s)
- Anna Clebone
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Scott C Watkins
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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Wolfler A, De Silvestri A, Camporesi A, Ivani G, Vittori A, Zadra N, Pasini L, Astuto M, Locatelli B, Cortegiani A, Disma N. Pediatric anesthesia practice in Italy: a multicenter national prospective observational study derived from the APRICOT Trial. Minerva Anestesiol 2020; 86:295-303. [DOI: 10.23736/s0375-9393.19.14126-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mondardini MC, Calderini E. Anesthesia in children: the protective role of expertise and experience. Minerva Anestesiol 2020; 86. [DOI: 10.23736/s0375-9393.20.14301-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Scheffenbichler FT, Rudolph MI, Friedrich S, Althoff FC, Xu X, Spicer AC, Patrocínio M, Ng PY, Deng H, Anderson TA, Eikermann M. Effects of high neuromuscular blocking agent dose on post-operative respiratory complications in infants and children. Acta Anaesthesiol Scand 2020; 64:156-167. [PMID: 31529484 DOI: 10.1111/aas.13478] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/15/2019] [Accepted: 09/03/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study evaluated the association between neuromuscular blocking agent dose and post-operative respiratory complications in infants and children. METHODS Data from 6507 general anaesthetics provided to children aged 0-10 years undergoing surgery were analysed to examine the effects of neuromuscular blocking agent dose on post-operative respiratory complications (primary endpoint) and secondary endpoints. Confounder-adjusted analyses addressed age, surgical duration, and comorbidity burden. RESULTS In confounder-adjusted analyses, high doses of neuromuscular blocking agents were associated with higher risk of post-operative respiratory complications (OR 2.27; 95% CI 1.12-4.59; P = .022). The effect was modified by age (P-for-interaction = .016) towards a more substantial risk in infants ≤1 year (OR 3.84; 95% CI 1.35-10.94; P = .012), by duration of surgery (P-for-interaction = .006) towards a higher difference in odds for surgeries <90 minutes (OR 4.25; 95% CI 1.19-15.18; P = .026), and by ASA physical status (P-for-interaction = .015) with a greater effect among patients with higher operative risk (ASA >1: OR 3.17; 95% CI 1.43-7.04; P = .005). Neostigmine reversal did not modify the association between neuromuscular blocking agents and post-operative respiratory complications (P-for-interaction = .38). Instrumental variable analysis confirmed that high doses of neuromuscular blocking agents were associated with post-operative respiratory complications (probit coefficient 0.25; 95% CI 0.04-0.46; P = .022), demonstrating robust results regarding concerns of unobserved confounding. CONCLUSIONS High dose of neuromuscular blocking agents is associated with post-operative respiratory complications. We have identified subcohorts of paediatric patients who are particularly vulnerable to the respiratory side-effects of neuromuscular blocking agents: infants, paediatric patients undergoing surgeries of short duration, and those with a high ASA risk score.
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Affiliation(s)
- Flora T. Scheffenbichler
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Maíra I. Rudolph
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Sabine Friedrich
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Friederike C. Althoff
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Aaron C. Spicer
- Department of Anesthesiology, Critical Care and Pain Medicine Boston Children’s Hospital and Harvard Medical School Boston MA USA
| | - Maria Patrocínio
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Pauline Y. Ng
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
- Adult Intensive Care Unit Queen Mary Hospital Hong Kong SAR China
| | - Hao Deng
- Department of Anesthesia Critical Care, and Pain Medicine Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Thomas A. Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine Lucile Packard Children's Hospital Stanford University School of Medicine Stanford CA USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Boston MA USA
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