Complications associated with paediatric airway management during the COVID-19 pandemic: an international, multicentre, observational study

Postoperative outcomes of pediatric patients with perioperative COVID-19 infection: a systematic review and meta-analysis of observational studies

OBJECTIVE

To quantify the risk of adverse postoperative outcomes in pediatric patients with COVID-19 infection.

METHODS

We searched PubMed, Embase, Cochrane Library from December 2019 to 21 April 2023. Observational cohort studies that reported postoperative early mortality and pulmonary complications of pediatric patients with confirmed COVID-19-positive compared with COVID-19-negative were eligible for inclusion. We excluded pediatric patients underwent organ transplantation or cardiac surgery. Reviews, case reports, letters, and editorials were also excluded. We used the Newcastle-Ottawa Scale to assess the methodological quality and risk of bias for each included study. The primary outcome was postoperative early mortality, defined as mortality within 30 days after surgery or during hospitalization. The random-effects model was performed to assess the pooled estimates, which were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

RESULTS

9 studies involving 23,031 pediatric patients were included, and all studies were rated as high quality. Compared with pediatric patients without COVID-19, pediatric patients with COVID-19 showed a significantly increased risk of postoperative pulmonary complications (PPCs) (RR = 4.24; 95% CI 2.08-8.64). No clear evidence was found for differences in postoperative early mortality (RR = 0.84; 95% CI 0.34-2.06), postoperative intensive care unit (ICU) admission (RR = 0.80; 95% CI 0.39-1.68), and length of hospital stay (MD = 0.35, 95% CI -1.81-2.51) between pediatric patients with and without COVID-19.

CONCLUSION

Perioperative COVID-19 infection was strongly associated with increased risk of PPCs, but it did not increase the risk of postoperative early mortality, the rate of postoperative ICU admission, and the length of hospital stay in pediatric patients. Our preplanned sensitivity analyses confirmed the robustness of our study findings.

Perioperative Respiratory-Adverse Events Following General Anesthesia Among Pediatric Patients After COVID-19

BACKGROUND

The perianesthetic morbidity, mortality risk and anesthesia-associated risk after preoperative coronavirus disease 2019 (COVID-19) omicron variant in pediatric patients have not been fully demonstrated. We examined the association between preoperative COVID-19 omicron diagnosis and the incidence of overall perioperative adverse events in pediatric patients who received general anesthesia.

METHODS

This retrospective study included patients aged < 18 years who received general anesthesia between February 1 and June 10, 2022, in a single tertiary pediatric hospital. They were divided into two groups; patients in a COVID-19 group were matched to patients in a non-COVID-19 group during the omicron-predominant period in Korea. Data on patient characteristics, anesthesia records, post-anesthesia records, COVID-19-related history, symptoms, and mortality were collected. The primary outcomes were the overall perioperative adverse events, including perioperative respiratory adverse events (PRAEs), escalation of care, and mortality.

RESULTS

In total, 992 patients were included in the data analysis (n = 496, COVID-19; n = 496, non-COVID-19) after matching. The overall incidence of perioperative adverse events was significantly higher in the COVID-19 group than in the non-COVID-19 group (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.89-1.94). The difference was significant for PRAEs (OR, 2.00; 95% CI, 1.96-2.02) but not in escalation of care or mortality. The most pronounced difference between the two groups was observed in instances of high peak inspiratory pressure ≥ 25 cmH2O during the intraoperative period (OR, 11.0; 95% CI, 10.5-11.4). Compared with the non-COVID-19 group, the risk of overall perioperative adverse events was higher in the COVID-19 group diagnosed 0-2 weeks before anesthesia (OR, 6.5; 95% CI, 2.1-20.4) or symptomatic on the anesthesia day (OR, 6.4; 95% CI, 3.30-12.4).

CONCLUSION

Pediatric patients with the preoperative COVID-19 omicron variant had increased risk of PRAEs. Patients within 2 weeks after COVID-19 or those with symptoms had a higher risk of PRAEs.

Association between preoperative respiratory symptoms and perioperative respiratory adverse events in pediatric patients with positive viral testing

STUDY OBJECTIVE

To determine the association between the presence of upper respiratory tract viral infection symptoms and occurrence of perioperative respiratory adverse events (PRAE) in children with positive viral screening, and to analyze the risk of PRAE in children with SARS-CoV-2 compared to non-SARS-CoV-2 infection.

DESIGN

A prospective cohort study.

SETTING

A tertiary, freestanding pediatric hospital in Dallas, Texas.

PATIENTS

Children <18 years of age with positive respiratory viral testing who underwent general anesthesia.

INTERVENTION

Measurement of incidence of PRAE and severe adverse events during the first 7 postoperative days.

MEASUREMENTS

The primary outcome was a composite of PRAE: oxygen saturation < 90% for >5 min, supplemental oxygen for >2 h after anesthesia, laryngospasm, and bronchospasm. The secondary outcome was severe adverse events: high flow nasal cannula >6 l of oxygen per minute, admission to the ICU for escalation of respiratory support post-anesthetic, acute respiratory distress syndrome, postoperative pneumonia, cardiovascular arrest, extracorporeal life support, and death.

MAIN RESULTS

In this convenience sample of 196 children, 83 were symptomatic and 113 were asymptomatic. The risk of PRAE was similar in children with active viral symptoms and asymptomatic children (risk difference: -1.9%; 95% CI: -10.9, 7.9%), but higher among children with documented fever within 48 h of the anesthetic (risk difference: 20.8%; 95% CI: 5.3, 39.7%). The multivariable adjusted odds ratio of PRAE was 0.68 (95% CI: 0.25, 1.85) for symptomatic compared to asymptomatic patients, and 0.46 (95% CI: 0.14, 1.44) for patients with SARS-CoV-2 compared to non-SARS-CoV-2 infection.

CONCLUSIONS

There was no significant difference in the incidence of PRAE between symptomatic and asymptomatic children with laboratory confirmed viral respiratory infection, and between children with the Omicron variant of SARS-CoV-2 compared to non-SARS-CoV-2 respiratory viruses. However, the risk was increased in children with recent fever.

[Children need sustainability]

The reduction of greenhouse gases such as CO2 emissions and their equivalents (CO2e) generally has three aspects: Fugitive direct emissions (anesthetic gases, exhaust gases), indirect emissions through the purchase of energy (electricity, heat) and emissions in the supply chain (supply of consumables, disposal). Since pediatric anesthesia has a traditional affinity with inhalation, the use of anesthetic gases should be repeatedly questioned and, if possible, avoided on the way to net zero emissions in addition to general measures to conserve resources. In children, analgosedation, total intravenous anesthesia (TIVA) and establishment of venous access prior to the induction of anesthesia are particularly suitable for this purpose. In addition to avoiding greenhouse gases, the methods mentioned offer other significant medical advantages and can also be profitable in terms of safety and comfort. Nevertheless, anesthetic gases are required in pediatric anesthesia in some situations. For this reason, it is important to save anesthetic gases through minimal fresh gas flow and a rational approach to inhalation induction. To facilitate implementation in clinical practice, this article provides recommendations for mask induction and choice of anesthetic procedure.

A retrospective report on the preoperative mandatory SARS-COV-2 infection screening in a single pediatric center. Is it time to stop testing our patients?

The novel coronavirus SARS-COV-2 (COVID-19) pandemic dramatically changed the workflow of healthcare professionals around the world. Surgical procedures were withheld and postponed in a scenario of fear and uncertainty. Despite numerous medical institutions having swiftly and widely implemented pre-operative screening protocols, cost-effective studies remain scarce specially when comparing to other mitigation measures such as the donning of masks and social distancing measures. The objective of our study is to report the monthly positivity rates of SARS-COV-2 infection in our service and compare our data with monthly positivity rates reported by the State Health Department. Between April, 2020, to February, 2022, 7,199 patients had the RT-PCR for SARS-COV-2 collected, with 187 (2.59%) testing positive for COVID-19. Most of them (62.1%) were asymptomatic. The most common symptoms were coryza (10.7%), fever (10%), and diarrhea (8.7%). Nonetheless, there were two deaths due to COVID-19 reported in our center. Further studies are necessary to elucidate the impact of pre-operative screening for SARS-COV-2 in asymptomatic patients.

Postanesthesia complications in pediatric patients with previous SARS-CoV-2 infection: A cohort study

BACKGROUND

Children with SARS-CoV-2 infection are at increased risk for postanesthesia complications. There is minimal data regarding how long that elevated complication risk persists beyond initial SARS-CoV-2 diagnosis.

AIMS

We investigated postanesthesia complications in children with SARS-CoV-2 infection within 90 days of diagnosis.

METHODS

We completed a single-center, retrospective, case-control study of pediatric patients with confirmed SARS-CoV-2 infection within 90 days undergoing anesthesia between January 3-October 7, 2020. Each SARS-CoV-2 positive patient was matched 1:2 by age and type of procedure with a non-SARS-CoV-2 cohort. The primary outcome was the rate of all postanesthesia complications within 30 days of the procedure, defined as unplanned escalations of care within 48 h, cardiac, respiratory, thrombotic, and hemorrhagic events within 30 days. Secondary outcomes were 30-day mortality and hospital length of stay.

RESULTS

Of the 341 patients included, 114 patients were SARS-CoV-2 positive and 227 were SARS-CoV-2 negative. Patients with a positive test 0-7 days prior to anesthesia had an increased risk difference in all postanesthesia complications within 30 days (19.9, 95% CI [4.7, 35.1], p = .001) and increased risk difference in length of hospital stay (7.8, 95% CI [1.2, 14.4], p < .001). Patients who underwent anesthesia greater than 42 days from SARS-CoV-2 diagnosis had an increased risk difference in cardiac complications within 30 days (4.3, 95% CI [0.9, 10.0], p = .029). There was no increased hospital length of stay among SARS-CoV-2 positive patients diagnosed greater than 8 days before anesthetic. There were no deaths within 30 days of anesthetic.

CONCLUSIONS

Postanesthesia complications are higher in children who undergo anesthesia within 7 days of SARS-CoV-2 diagnosis. Additional cardiac risk may persist beyond the immediate period of initial diagnosis. Larger samples are needed to further evaluate the risk of delayed postanesthesia complications and guide optimal timing of surgery.

Anaesthesia in SARS-CoV-2 infected children - single-centre experience. A case-control study

INTRODUCTION

Although manifestation of SARS-CoV-2 infection in children is gene-rally mild or asymptomatic, anaesthetic implications of the infection in children are still a matter of concern. Single reports suggest that patients with SARS-CoV-2 infection are at higher risk of anaesthetic complications.

MATERIAL AND METHODS

We performed a retrospective, case control study analysing the risk of general anaesthesia in SARS-CoV-2 infected children admitted to a tertiary paediatric university hospital for the purpose of urgent procedures requiring anaesthesia  between April 1st and September 30 th , 2021. The control group consisted of  SARS-CoV-2 negative children consecutively anaesthetised for the same reasons during the first month of observation. Our hypothesis was: general anaesthesia can be safely performed in SARS-CoV-2 infected children. Study endpoints: primary - anaesthetic respiratory complications (bronchospasm, laryngospasm, intraoperative desaturation below 94%, desaturation below 94% after awakening, unplanned postoperative mechanical ventilation); secondary - hospital length of stay, thrombotic, cardiac, haemorrhagic events, ICU admission, deaths during hospitalisation.

RESULTS

The examined group consisted of 58 SARS-CoV-2 infected children, the matched control group of 198 patients. The rate of complications in both groups was very low, with no significant difference between the groups. The only differences observed were a higher frequency of desaturations in the awakening period and longer time of hospitalisation in SARS-CoV-2 infected patients. Multivariate logistic regression analysis showed that physical status of the patient and duration of the procedure were the main factors influencing the risk of complications.

CONCLUSIONS

In our experience anaesthesia of SARS-CoV-2 infected children can be safely performed.

Estudo retrospectivo de rastreamento pré-operatoria mandatória de SARS-COV-2 na população pediátrica. Será hora de parar de testar nossos pacientes?

RESUMO A pandemia causada pelo novo coronavírus (SARS-COV-2) alterou a rotina de pacientes, profissionais e serviços de saúde em todo o mundo levando ao adiamento ou suspensão de muitos procedimentos cirúrgicos. Muitos serviços implementaram protocolos de triagem sistemática pré-operatória para SARS-COV-2. No entanto, segue incerta a eficácia da triagem sistemática de pacientes assintomáticos para SARS-COV-2 quando comparada com outras medidas de mitigação como o uso de máscaras e o distanciamento social apesar da aparente sensação de segurança conferida pela testagem pré-operatória de pacientes para SARS-COV-2. Sendo assim, descrevemos a experiência de dois anos de um hospital pediátrico (n=7.199) na triagem sistemática pré-operatória para SARS-COV-2 e comparamos a taxa de positividade mensal reportada pelo serviço em relação a taxa de positividade mensal regional do Estado de São Paulo. No período de Abril de 2020 a Fevereiro de 2022 houveram 187 (2,56%) RT-PCR positivos para COVID-19 dos quais 62.1% assintomáticos. Os sintomas mais comuns foram coriza (10,7%), febre (10%) e diarreia (8,7%). Dois pacientes faleceram em decorrência de sintomas relacionados a COVID-19. Mais estudos são necessários para determinar o impacto da testagem pré-operatória de RT-PCR para SARS-COV-2 em pacientes assintomáticos na mitigação da transmissão intra-hospitalar e na morbidade cirúrgica.