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Kaufmann J, Huber D, Engelhardt T, Kleine-Brueggeney M, Kranke P, Riva T, von Ungern-Sternberg BS, Fuchs A. [Airway management in neonates and infants : Recommendations according to the ESAIC/BJA guidelines]. DIE ANAESTHESIOLOGIE 2024; 73:473-481. [PMID: 38958671 PMCID: PMC11222175 DOI: 10.1007/s00101-024-01424-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Securing an airway enables the oxygenation and ventilation of the lungs and is a potentially life-saving medical procedure. Adverse and critical events are common during airway management, particularly in neonates and infants. The multifactorial reasons for this include patient-dependent, user-dependent and also external factors. The recently published joint ESAIC/BJA international guidelines on airway management in neonates and infants are summarized with a focus on the clinical application. The original publication of the guidelines focussed on naming formal recommendations based on systematically documented evidence, whereas this summary focusses particularly on the practicability of their implementation.
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Affiliation(s)
- Jost Kaufmann
- Kinderkrankenhaus der Kliniken der Stadt Köln gGmbH, Amsterdamer Str. 59, 50735, Köln, Deutschland.
- Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland.
| | - Dennis Huber
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| | - Thomas Engelhardt
- Department of Anesthesiology, Montreal Children's Hospital, McGill University, Montreal, QC, Kanada
| | - Maren Kleine-Brueggeney
- Klinik für Kardioanästhesiologie und Intensivmedizin, Deutsches Herzzentrum der Charité (DHZC), Berlin, Deutschland
- Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität Berlin und Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Thomas Riva
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australien
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australien
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, WA, Australien
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australien
| | - Alexander Fuchs
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
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Braz LG, Braz JRC, Tiradentes TAA, Porto DDSM, Beserra CM, Vane LA, Nascimento Junior PD, Modolo NSP, Braz MG. An update on the mechanisms and risk factors for anesthesia-related cardiac arrest in children: a narrative review. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844519. [PMID: 38810776 DOI: 10.1016/j.bjane.2024.844519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/03/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024]
Abstract
The relation between surgery and anesthesia safety in children and a country's Human Development Index (HDI) value has been described previously. The aim of this narrative review was to provide an update on the mechanisms and risk factors of Anesthesia-Related Cardiac Arrest (ARCA) in pediatric surgical patients in countries with different HDI values and over time (pre-2001 vs. 2001‒2024). Electronic databases were searched up to March 2024 for studies reporting ARCA events in children. HDI values range from 0 to 1 (very-high-HDI countries: ≥ 0.800, high-HDI countries: 0.700‒0.799, medium-HDI countries: 0.550‒0.699, and low-HDI countries: < 0.550). Independent of time, the proportion of children who suffered perioperative Cardiac Arrest (CA) attributed to anesthesia-related causes was higher in very-high-HDI countries (50%) than in countries with HDI values less than 0.8 (15‒36%), but ARCA rates were higher in countries with HDI values less than 0.8 than in very-high-HDI countries. Regardless of the HDI value, medication-related factors were the most common mechanism causing ARCA before 2001, while cardiovascular-related factors, mainly hypovolemia, and respiratory-related factors, including difficulty maintaining patent airways and adequate ventilation, were the major mechanisms in the present century. Independent of HDI value and time, a higher number of ARCA events occurred in children with heart disease and/or a history of cardiac surgery, those aged younger than one year, those with ASA physical status III‒V, and those who underwent emergency surgery. Many ARCA events were determined to be preventable. The implementation of specialized pediatric anesthesiology and training programs is crucial for anesthesia safety in children.
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Affiliation(s)
- Leandro Gobbo Braz
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil.
| | - Jose Reinaldo Cerqueira Braz
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil
| | - Teofilo Augusto Araújo Tiradentes
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil
| | - Daniela de Sa Menezes Porto
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil
| | - Cristiano Martins Beserra
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil
| | - Luiz Antonio Vane
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil
| | - Paulo do Nascimento Junior
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil
| | - Norma Sueli Pinheiro Modolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil
| | - Mariana Gobbo Braz
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Comissão de Estudos de Parada Cardíaca e Mortalidade em Anestesia, Botucatu, SP, Brazil
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth 2024; 132:124-144. [PMID: 38065762 DOI: 10.1016/j.bja.2023.08.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/30/2023] [Indexed: 01/05/2024] Open
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan
| | - Evelien Cools
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - John Fiadjoe
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexander Fuchs
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annery Garcia-Marcinkiewicz
- Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Chloe Heath
- Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand; Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia
| | - Mathias Johansen
- Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jost Kaufmann
- Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany; Faculty for Health, University of Witten/Herdecke, Witten, Germany
| | - Maren Kleine-Brueggeney
- Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Pete G Kovatsis
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Andrea C Lusardi
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Peyton
- Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Carolina S Romero
- Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain
| | - Britta von Ungern-Sternberg
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia
| | | | - Arash Afshari
- Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Disma N, Asai T, Cools E, Cronin A, Engelhardt T, Fiadjoe J, Fuchs A, Garcia-Marcinkiewicz A, Habre W, Heath C, Johansen M, Kaufmann J, Kleine-Brueggeney M, Kovatsis PG, Kranke P, Lusardi AC, Matava C, Peyton J, Riva T, Romero CS, von Ungern-Sternberg B, Veyckemans F, Afshari A. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Eur J Anaesthesiol 2024; 41:3-23. [PMID: 38018248 PMCID: PMC10720842 DOI: 10.1097/eja.0000000000001928] [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] [Indexed: 11/30/2023]
Abstract
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1С). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1С). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO 2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
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Affiliation(s)
- Nicola Disma
- From the Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy (ND, AF, ACL), Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan (TA), Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland (EC, WH), Medical Library, Boston Children's Hospital, Boston, MA, USA (AC), Department of Anaesthesia, Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada (TE, MJ), Department of Anaesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA (JF, PGK, JP), Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA (AG-M), Department of Anaesthesia and Pain Management, Starship Children's Hospital, Auckland, New Zealand (CH), Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australia (CH, BvU-S), Department for Pediatric Anesthesia, Children's Hospital Cologne, Cologne, Germany (JK), Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK), Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC) and Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany (MK-B), Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany (PK), Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada (CM), Department of Anesthesia and Critical Care, Consorcio Hospital General Universitario de Valencia, Methodology Department, Universidad Europea de Valencia, Valencia, Spain (CSR), Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia (BvU-S), Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia (BvU-S), Faculty of Medicine, UCLouvain, Brussels, Belgium (FV), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark (AA)
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Park JB, Sohn JY, Kang P, Ji SH, Kim EH, Lee JH, Kim JT, Kim HS, Jang YE. Perioperative Respiratory-Adverse Events Following General Anesthesia Among Pediatric Patients After COVID-19. J Korean Med Sci 2023; 38:e349. [PMID: 38050910 PMCID: PMC10695756 DOI: 10.3346/jkms.2023.38.e349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/05/2023] [Indexed: 12/07/2023] Open
Abstract
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.
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Affiliation(s)
- Jung-Bin Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Young Sohn
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Pyoyoon Kang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Hwan Ji
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.
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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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Mamaril ME, MacDonald R. Documentation of Assessments and Interventions Using a Pediatric Preoperative Risk Assessment Checklist in the Postanesthesia Care Unit: A Quality Improvement Initiative. J Perianesth Nurs 2023; 38:693-702. [PMID: 37269275 DOI: 10.1016/j.jopan.2023.01.009] [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: 08/21/2022] [Revised: 12/22/2022] [Accepted: 01/07/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE Describe the impact of the implementation of an evidence-based pediatric preoperative risk assessment (PPRA) checklist on the frequency of postanesthesia care unit (PACU) nursing assessments and interventions in children at risk for respiratory complications during emergence from anesthesia. DESIGN Prospective pre-/postdesign. METHODS Pediatric perianesthesia nurses assessed 100 children preintervention according to current standard. After nurses received pediatric preoperative risk factor (PPRF) education, another 100 children were assessed postintervention using the PPRA checklist. Pre-/postpatients were unmatched for statistical purposes due to two different groups. Frequency of PACU nursing respiratory assessments/interventions was evaluated. FINDINGS Demographic variables, risk factors, frequency of nursing assessments/interventions were summarized in pre-/postinterventions. Significant differences (P < .001) were noted between pre-/postintervention groups with increased frequency of postnursing assessments/interventions that correlated with increased risk factors and weighted risk factors. CONCLUSIONS By identifying total PPRFs, PACU nurses used their plan of care to frequently assess and pre-emptively intervene with children who had increased risk factors to prevent or mitigate respiratory complications on emergence from anesthesia.
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Affiliation(s)
- Myrna E Mamaril
- Perioperative Services, Johns Hopkins Hospital, Baltimore, MD.
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Rattana-Arpa S, Chaikittisilpa N, Srikongrak S, Udomnak S, Aroonpruksakul N, Kiatchai T. 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. Eur J Anaesthesiol 2023; 40:483-494. [PMID: 37191165 PMCID: PMC10256306 DOI: 10.1097/eja.0000000000001848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
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.
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Affiliation(s)
- Sirirat Rattana-Arpa
- From the Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Hamilton ARL, Odegard KC, Yuki K. Exploring Noncardiac Surgical Needs From Infancy to Adulthood in Patients With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2022; 36:4364-4369. [PMID: 36216687 DOI: 10.1053/j.jvca.2022.09.076] [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] [Received: 06/08/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES As life expectancy for patients born with congenital heart disease (CHD) continues to rise, these patients will present increasingly for noncardiac surgery during childhood and adolescence. This study aimed to map the lifespan of noncardiac surgical needs among patients with CHD and explore how these needs may change over time. DESIGN All patients with CHD presenting for noncardiac surgery between 2008 and 2014 were selected for review. SETTING The study was conducted at a single urban academic tertiary pediatric hospital. PARTICIPANTS All patients with CHD presenting for noncardiac surgery during the study period were included and grouped by cardiac diagnosis. INTERVENTIONS Descriptive analysis included patient demographics, CHD diagnosis, procedures performed, and clinical data, including baseline saturation and underlying cardiac function. MEASUREMENTS AND MAIN RESULTS A total of 3,011 noncardiac surgical procedures were performed on patients with CHD during the study period. The most common CHD diagnoses were patent ductus arteriosus (27.6%), ventricular septal defects (24.7%), and patent foramen ovale (24.3%). The median age was 4 years, 87% of all the patients were ≤10 years, and 41% had associated syndromes. Of the patients, 76% underwent a preoperative echocardiogram, and 10% had depressed cardiac function at the time of surgery. The most common procedures performed were ear, nose, and throat (20%), general surgery (14%), and radiology (11%). Intraoperative events were reported in 488 out of 3,010 encounters (16.2%), with the highest rates reported in patients with single-ventricle physiology (55/179; 30.7%). CONCLUSIONS These findings suggested a greater burden of noncardiac surgery in lower age groups, with ear, nose, and throat and general surgery most common in young children and orthopedic and dental procedures increasing in adolescence.
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Affiliation(s)
- A Rebecca L Hamilton
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA; Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden.
| | - Kirsten C Odegard
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Koichi Yuki
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA
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Braz LG, Tiradentes TAA, Braz JR. Comment on: Global mortality of children after perioperative cardiac arrest: A systematic review, meta-analysis, and meta-regression. Ann Med Surg (Lond) 2022; 79:103970. [PMID: 35757306 PMCID: PMC9213694 DOI: 10.1016/j.amsu.2022.103970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/06/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
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Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med 2022; 80:485-496. [PMID: 35752522 DOI: 10.1016/j.annemergmed.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/22/2022] [Accepted: 04/29/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm. METHODS Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium. The primary outcome was laryngospasm. The independent variables in the multivariable model included American Society of Anesthesiologists category, age, sex, concurrent upper respiratory infection, medication regimen, hospital sedation location, whether the procedure was painful, and whether the procedure involved the airway. The analysis included adjusted odds ratios (aORs) and predicted probabilities. RESULTS We analyzed 276,832 sedations with 913 reported events of laryngospasm (overall unadjusted prevalence 3.3:1,000). A younger age, a higher American Society of Anesthesiologists category, a concurrent upper respiratory infection (aOR 3.94, 2.57 to 6.03; predicted probability 12.2/1,000, 6.3/1,000 to 18.0/1,000), and airway procedures (aOR 3.73, 2.33 to 5.98; predicted probability 9.6/1,000, 5.2/1,000 to 13.9/1,000) were associated with increased risk. Compared with propofol alone, propofol combination regimens had increased risk (propofol+ketamine: aOR 2.52, 1.41 to 4.50; predicted probability 7.6/1,000, 3.1/1,000 to 12/1,000; and propofol+dexmedetomidine: aOR 2.10, 1.25 to 3.52; predicted probability 6.3/1,000, 3.7,/1,000 to 8.9/1,000). Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%). CONCLUSION We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types, and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decisionmaking.
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Affiliation(s)
- Peter Cosgrove
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatric Emergency Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK.Dr Cosgrove is currently affiliated with Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK.
| | - Baruch S Krauss
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Joseph P Cravero
- Department of Anesthesia, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Development of an Evidence-Based Pediatric Preoperative Risk Assessment Checklist. J Perianesth Nurs 2022; 37:589-594.e2. [DOI: 10.1016/j.jopan.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/14/2020] [Accepted: 12/26/2020] [Indexed: 11/18/2022]
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Buis ML, Turner NM. New European Resuscitation Council guidelines for pediatric life support and their implications for pediatric anesthesia: An educational article. Paediatr Anaesth 2022; 32:497-503. [PMID: 34964208 DOI: 10.1111/pan.14389] [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] [Received: 10/13/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Maria L Buis
- Consultant Pediatric Anesthesiologist, Juliana Children's Hospital & Haga Hospital, The Hague, The Netherlands
| | - Nigel M Turner
- Consultant Pediatric Anesthesiologist and Educationalist, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
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Zhang Q, Shen F, Wei Q, Liu H, Li B, Zhang Q, Zhang Y. Development and Validation of a Risk Nomogram Model for Perioperative Respiratory Adverse Events in Children Undergoing Airway Surgery: An Observational Prospective Cohort Study. Risk Manag Healthc Policy 2022; 15:1-12. [PMID: 35023976 PMCID: PMC8747787 DOI: 10.2147/rmhp.s347401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/23/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose The aim of this study was to explore the associated risk factors of perioperative respiratory adverse events (PRAEs) in children undergoing airway surgery and establish and validate a nomogram prediction model for PRAEs. Patients and Methods This study involved 709 children undergoing airway surgery between November 2020 and July 2021, aged ≤18 years in the affiliated hospital of Xuzhou Medical University. They were divided into training (70%; n = 496) and validation (30%; n = 213) cohorts. The least absolute shrinkage and selection operator (LASSO) was used to develop a risk nomogram model. Concordance index values, calibration plot, decision curve analysis, and the area under the curve (AUC) were examined. Results PRAEs were found in 226 of 496 patients (45.6%) and 88 of 213 patients (41.3%) in the training and validation cohorts, respectively. The perioperative risk factors associated with PRAEs were age, obesity, degree of upper respiratory tract infection, premedication, and passive smoking. The risk nomogram model showed good discrimination power, and the AUC generated to predict survival in the training cohort was 0.760 (95% confidence interval, 0.695–0.875). In the validation cohort, the AUC of survival predictions was 0.802 (95% confidence interval, 0.797–0.895). Calibration plots and decision curve analysis showed good model performance in both datasets. The sensitivity and specificity of the risk nomogram model were calculated, and the result showed the sensitivity of 69.5% and 64.8% and specificity of 73.3% and 81.6% for the training and validation cohorts, respectively. Conclusion The present study showed the proposed nomogram achieved an optimal prediction of PRAEs in patients undergoing airway surgery, which can provide a certain reference value for predicting the high-risk population of perioperative respiratory adverse events and can lead to reasonable preventive and treatment measures.
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Affiliation(s)
- Qin Zhang
- Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - Fangming Shen
- Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - Qingfeng Wei
- Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - He Liu
- Department of Anesthesiology, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine; Huzhou Central Hospital, Huzhou City, Zhejiang Province, People's Republic of China
| | - Bo Li
- Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - Qian Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
| | - Yueying Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, Jiangsu Province, People's Republic of China
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Chaïbou MS, Daddy H, Dan Mallam MK, Gagara M, James-Didier L, Sani R, Abarchi H. Prospective, observational study of perioperative critical incidents, anaesthesia and mortality in elective paediatric surgical patients at a national referral hospital in Niger. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2022. [DOI: 10.36303/sajaa.2022.28.1.2462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- MS Chaïbou
- Department of Anaesthesia, Niamey National Hospital,
Niger
| | - H Daddy
- Department of Anaesthesia, Niamey National Hospital,
Niger
| | - MK Dan Mallam
- Department of Anaesthesia, Niamey National Hospital,
Niger
| | - M Gagara
- Department of Anaesthesia, Niamey National Hospital,
Niger
| | - L James-Didier
- Department of Surgery, Lamorde National Hospital, Niamey
| | - R Sani
- Department of Surgery, Lamorde National Hospital, Niamey
| | - H Abarchi
- Department of Surgery, Lamorde National Hospital, Niamey
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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. Anesth Analg 2021; 134:728-739. [PMID: 34928873 DOI: 10.1213/ane.0000000000005796] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Identifying studies on medication error in anaesthesiology. Comment on Br J Anaesth 2021; 127: 458-69. Br J Anaesth 2021; 128:e12-e13. [PMID: 34823873 DOI: 10.1016/j.bja.2021.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/21/2022] Open
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Vishneski SR, Nagatsuka M, Smith LD, Templeton TW, Downard MG, Goenaga-Diaz EJ, Templeton LB. It's Not Over Till It's Over: A Prospective Cohort Study and Analysis of "Anesthesia Stat!" Emergency Calls in the Pediatric Post-Anesthesia Care Unit (PACU). Cureus 2021; 13:e17571. [PMID: 34646626 PMCID: PMC8480442 DOI: 10.7759/cureus.17571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 11/07/2022] Open
Abstract
Background Emergency "Anesthesia Stat!" (AS!) calls remain a common practice in medical centers even when advanced communication infrastructures are available. We hypothesize that the analysis of post-procedure "AS!" calls will lead to actionable insights which may enhance patient safety. Methods After institutional review board approval, we prospectively collected data from April 2015 through May 2018 on "AS!" calls throughout the pediatric operating rooms (OR), off-site locations, and post-anesthesia care unit (PACU) at a tertiary university medical center. Data recorded included demographic information, location, time of the event, event duration, vital signs, medications, anesthesia staff, attending anesthesiologist, and staff responding to the call. A narrative account of the event was also documented. Results A total of 82 "AS!" calls occurred, with ages ranging from 11 days old to 17 years old. Forty-nine of the 82 calls (60%) occurred at emergence. Seventy-one of the 82 calls (87%) were solely respiratory-related. Thirty-five of 49 emergence calls (71%) occurred in the PACU. Further, 34 of 35 PACU calls (97%) were respiratory-related, with 30 of 35 PACU calls (86%) associated with desaturation requiring intervention by anesthesia staff. Finally, 31 of 35 PACU calls (89%) occurred within 30 minutes of patient arrival to PACU. Conclusion Analysis of "AS!" events from our PACU continues to support the need for the prompt and continuous availability of at least one staff member with advanced airway management skills. Further, pediatric patients undergoing general anesthesia and surgery should likely be monitored for a minimum of 30 minutes following arrival in the PACU.
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Affiliation(s)
- Susan R Vishneski
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Moeko Nagatsuka
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, USA
| | - L D Smith
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, USA
| | - T W Templeton
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Martina G Downard
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, USA
| | | | - Leah B Templeton
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, USA
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Raghavan KC, Hache M, Bulsara P, Lu Z, Rossi MG. Perianesthetic neurological adverse events in children: A review of the Wake-Up Safe Database. Paediatr Anaesth 2021; 31:594-603. [PMID: 33630312 DOI: 10.1111/pan.14165] [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] [Received: 05/04/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perianesthetic neurological adverse events are rare in children and have been studied in detail in the settings of cardiac surgery and regional anesthesia. Our study aims to characterize perianesthetic neurological adverse events in children in the setting of all types of surgery and diagnostic or interventional procedures, to evaluate anesthesia's role, and to identify factors amenable to prevention. METHODS We conducted a retrospective study by reviewing all the anesthetic encounters reported in the Wake-Up Safe database between January 2010 and December 2017. RESULTS The rate of perianesthetic neurological adverse events was 0.49 per 10 000 pediatric anesthetic encounters. The odds of NAE were significantly higher in children who were older than 6 months; had American Society of Anesthesiologists physical status (ASA PS) of 3, 4, or 5; or had American Society of Anesthesiologists Emergency (ASA E) status. Seizures were the most common NAE. Overall, 23 (18.1%) children with neurological adverse events died, and 33 (26%) experienced permanent or severe permanent harm. The risk of death was higher in infants and in children with ASA PS of 3, 4, or 5; ASA E status; preexisting neurological abnormality; or preexisting neurological deficit and in events associated with cardiac arrest or trauma. Anesthesia contributed to 24 (18.9%) events; patient disease was the primary causative factor in 95 (74.8%) adverse events, and 37 (29.1%) events were preventable, including 2 deaths. Preventable factors broadly included inadequate preoptimization, complications during airway management and central venous catheter placement, and suboptimal patient positioning. CONCLUSION Perianesthetic neurological adverse events are rare in children and have a poor outcome. Our study has described pediatric perianesthetic neurological injury in detail and identified contributing factors that can be optimized during various phases of perianesthetic care. This information can be utilized during the informed consent process and to enhance the quality of care in children receiving anesthesia.
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Affiliation(s)
- Kavitha C Raghavan
- Division of Anesthesiology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Manon Hache
- Department of Anesthesiology, Division of Pediatric Anesthesia, Columbia University Medical Center, New York, NY, USA
| | - Purva Bulsara
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Zhaohua Lu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Michael G Rossi
- Division of Anesthesiology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Kopczynski K, Meyer BD. Examining Parental Treatment Decisions Within a Contemporary Pediatric Dentistry Private Practice. Patient Prefer Adherence 2021; 15:645-652. [PMID: 33790544 PMCID: PMC8007596 DOI: 10.2147/ppa.s300684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/22/2021] [Indexed: 12/01/2022] Open
Abstract
PURPOSE The primary objective of this study was to compare relationships between child, parent, and clinical factors with patient-level treatment decisions for early childhood caries. A secondary objective was to describe children that received silver diamine fluoride (SDF) as interim versus long-term treatment. PATIENTS AND METHODS Parents of 2-6-year-old children seeking care at a multi-center pediatric dentistry private practice were enrolled in this cross-sectional study. Demographic data and dental anxiety data according to the Modified Corah's Dental Anxiety Scale were collected via questionnaire. A dental visit behavior rating and decayed, missing, and filled tooth (dmft) index were recorded from the child's dental record. The primary outcome was treatment decision categorized into three groups: (1) treatment with SDF (n=25), (2) conventional restorative treatment under local anesthesia (n=32), and (3) restorative treatment under general anesthesia (n=33). Analyses included descriptive statistics, bivariate analysis, and ordered logistic regression. RESULTS Child age, parent education level, family income, dental insurance status, dental visit behavior rating, and dmft were significantly different across treatment groups in bivariate comparisons. However, when included in multivariable, ordered logistic regression, child dental anxiety was the only significant covariate associated with treatment decisions (Odds Ratio=5.01, 95% confidence interval: 1.51 to 16.63). In secondary analysis, two distinct subgroups were identified within the SDF group: one as long-term treatment (n=9) and one as interim treatment prior to general anesthesia (n=16). The long-term group was younger (mean=3.2 versus 3.7), had lower dmft (mean=4 versus 11.1), and had lower frequency of very high dental anxiety (0% versus 15%). CONCLUSION The present study identified child dental anxiety as the primary factor associated with treatment decisions at this private practice. The characterization of two subgroups of children treated with SDF has meaningful implications for studies evaluating the economic and public health impacts of SDF.
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Affiliation(s)
- Kayla Kopczynski
- Adams School of Dentistry, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Beau D Meyer
- Division of Pediatric Dentistry, College of Dentistry, Ohio State University, Columbus, OH, USA
- Correspondence: Beau D Meyer The Ohio State University, College of Dentistry, Division of Pediatric Dentistry, Columbus, OH, USA Email
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de Graaff JC, Johansen MF, Hensgens M, Engelhardt T. Best practice & research clinical anesthesiology: Safety and quality in perioperative anesthesia care. Update on safety in pediatric anesthesia. Best Pract Res Clin Anaesthesiol 2020; 35:27-39. [PMID: 33742575 DOI: 10.1016/j.bpa.2020.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/03/2020] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, the Netherlands.
| | - Mathias Fuglsang Johansen
- Division Pediatric Anesthesia, Montreal Children's Hospital, McGill University Centre, Montreal, Canada
| | - Martinus Hensgens
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, the Netherlands
| | - Thomas Engelhardt
- Division Pediatric Anesthesia, Montreal Children's Hospital, McGill University Centre, Montreal, Canada
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Kim YM, Lee JH, Kim HS, Kim JS, Yang HS. Analysis of perioperative cardiac arrest in a rural hospital in Korea. Anesth Pain Med (Seoul) 2020; 15:325-333. [PMID: 33329832 PMCID: PMC7713834 DOI: 10.17085/apm.20001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
Background Perioperative cardiac arrest has been studied in many countries but few related studies have been conducted in Korea. Previous studies were not applicable to rural hospitals due to differences in the demographics between the regions. In the present study, the incidence, mortality, and related factors of perioperative cardiac arrest in a hospital in Youngdong province were analyzed and compared with previous research. Methods A retrospective study was conducted from the January 1, 2012, to December 31, 2018, on patients who underwent both anesthesia and surgery in our hospital. Patients who received local anesthesia were not included in the study. The collected data included the patient characteristics, anesthesia methods, the American Society of Anesthesiologists physical status, surgical department, emergency status, traumatic status, pre- and post-cardiac arrest medical records, and patient outcomes. Results A total of 57,746 patients received anesthesia and underwent surgery during the study period, and 28 patients (4.85 per 10,000 anesthesia cases) received cardiopulmonary cerebral resuscitation (CPCR) during or within 24 h of surgery. Eight patients survived and twenty patients died (3.46 per 10,000 anesthesia cases). There were three anesthesia-related arrests and all of these patients survived. When limiting the analysis to patients with intraoperative CPCR, the incidence and mortality were 1.56, and 1.39 per 10,000 anesthesia cases, respectively. Conclusions The incidence and mortality of perioperative cardiac arrest in our hospital were higher than those in a recent study in Seoul, demonstrating a regional gap in Korea.
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Affiliation(s)
- Young-Mu Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jae-Ho Lee
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Hyun-Soo Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jin Sun Kim
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Hong-Seuk Yang
- Department of Anesthesiology and Pain Medicine, Daejeon Sun Medical Center, Daejeon, Korea
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Outcomes and complications of immediate versus delayed sequential bilateral cataract surgery in children. J AAPOS 2020; 24:137.e1-137.e6. [PMID: 32497580 DOI: 10.1016/j.jaapos.2020.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 02/04/2020] [Accepted: 02/08/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE To present the largest series to date comparing outcomes and complications of immediate versus delayed sequential bilateral cataract surgery (ISBCS vs DSBCS) in children at a single center over a 10-year period. METHODS The medical records of children <2 years of age who underwent ISBCS and DSBCS were reviewed retrospectively. Data was collected on outcomes and complications (ophthalmological and anesthesia-related) up to 8 weeks postoperatively. RESULTS A total of 53 children were included: 37 ISBCS and 16 DSBCS. There were no differences between groups with regard to sex, age at surgery, and type of surgery. The ISBCS group had significantly more patients with systemic or ocular comorbidities than the DSBCS group (35% vs 6%; P = 0.029). Mean operating room time was significantly lower for the ISBCS group (3.61 vs 4.09 hours; P = 0.037), whereas total surgical time was similar. No major intraoperative surgical complications or anesthesia-related adverse events occurred in either group. Postoperative complications (most commonly, raised intraocular pressure) occurred in 5 eyes (7%) in the ISBCS group and 8 eyes (25%) in the DSBCS group (P = 0.009). Patients in the ISBCS group required significantly fewer follow-up visits compared to the DSBCS group (4 vs 6; P = 0.0002). CONCLUSIONS ISBCS avoids multiple anesthesia sessions and reduces follow-up visits, with intra- and postoperative ophthalmological or anesthesia-related complications comparable to DSBCS.
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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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Eizaga Rebollar R, García Palacios MV, Fernández Mangas MC, Arroyo Fernández FJ, Márquez Rodríguez CM, Carnota Martín AI, Morales Guerrero J, Torres Morera LM. «Safety First»: Design of an anesthetic checklist in pediatrics. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2019; 66:459-466. [PMID: 31582277 DOI: 10.1016/j.redar.2019.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/30/2019] [Accepted: 06/24/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Quality improvement in health care entails the design of reliable processes which prevent and mitigate medical errors. Checklists are cognitive tools which reduce such errors. The primary objective of this study was to design an anesthetic checklist in Pediatrics to be implemented in our hospital. METHODS Delphi technique was used, with 3 rounds of questionnaire surveys: a generic questionnaire to obtain dimensions and items; and 2 specific ones to score individual items and obtain an overall rating for the checklist (median), and to measure the level of consensus (relative interquartile range) and internal reliability (Wilcoxon signed-rank test). RESULTS Final version of the checklist obtained a high overall score (Med 9) with a very high consensus (RIR 5%). Internal consensus was reached on all items (RIR ≤ 30%). Wilcoxon signed-rank test found no statistically significant differences, demonstrating reliability or consistency of responses between consecutive rounds. CONCLUSION The Anesthetic checklist in Pediatrics has been methodically designed for implementation and use in our hospital.
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Affiliation(s)
- R Eizaga Rebollar
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Mar, Cádiz, España.
| | - M V García Palacios
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Puerta de Mar, Cádiz, España
| | - M C Fernández Mangas
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Mar, Cádiz, España
| | - F J Arroyo Fernández
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Mar, Cádiz, España
| | - C M Márquez Rodríguez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Mar, Cádiz, España
| | - A I Carnota Martín
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Mar, Cádiz, España
| | - J Morales Guerrero
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Mar, Cádiz, España
| | - L M Torres Morera
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Mar, Cádiz, España
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Hansen TG, Børke WB, Isohanni MH, Castellheim A. Incidence of severe critical events in paediatric anaesthesia in Scandinavia: Secondary analysis of Anaesthesia PRactice In Children Observational Trial (APRICOT). Acta Anaesthesiol Scand 2019; 63:601-609. [PMID: 30729498 DOI: 10.1111/aas.13333] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/07/2018] [Accepted: 01/04/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Anaesthesia PRactice In Children Observational Trial (APRICOT) in 261 European hospitals revealed a 5.2% incidence of severe critical events in the perioperative period and wide variability in practice. METHODS A sub-analysis of the Scandinavian data was undertaken to investigate differences from the rest of Europe in the incidence and nature of perioperative severe critical events and to attempt to identify areas for quality improvement. FINDINGS In the Scandinavian cohorts of 1520 paediatric patients out of 31 127 patients, the overall incidence of perioperative severe critical events was lower than the rest of Europe (4.4% (95% CI [3.5-5.6]) vs 5.2% (95% CI [5.0-5.5]); RR 0.57), albeit the incidence varied across countries. There was a lower rate of bronchospasm (0.9%), stridor (1.1%) and cardiovascular instability (0.9%) than the rest of Europe. The proportion of bronchospasm events occurring at induction was 0.13% in Scandinavian cohort which was less than the rest of Europe (1.2%). The proportion of sicker patients where less experienced teams were managing the care was notably lower in Scandinavia than in the rest of Europe (14.4% vs 20.4% of the American Society of Anesthesiologists Physical Status Classification System Score (ASA-PS III and 8.3% vs 12.8% of the ASA-PS IV. Cardiovascular instability was lower in Scandinavia (0.92%) compared to Europe (1.9%). The incidence of drug errors was low in both the overall APRICOT (0.2%) and in Scandinavia (0.3%). There were no deaths. INTERPRETATION This sub-analysis shows that current Scandinavia paediatric perioperative clinical practice compares favourably with the rest of Europe. The lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated paediatric anaesthesia providers managing the higher risk groups of patients in Scandinavia. Whether this cohort of anaesthetized children is truly representative of the entire Scandinavia countries is unknown. Areas for quality improvement include: standardisation of the definition of severe critical events, increased reporting, development of evidence-based protocols for the management of severe critical events, development and rational implementation of paediatric perioperative risk assessment scores, implementation of current best practice in the provision of competent paediatric anaesthesia service in Europe, development of specific training and ensuring maintenance skills in paediatric anaesthesia. Furthermore, based on data from the original Apricot paper children under the age of 3 years and ASA-PS III and IV patients should not be anaesthetised without direct supervision of a specialist in paediatric anaesthesia. Given the sample size of the Scandinavian cohort this conclusion cannot be investigated further.
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Affiliation(s)
- Tom G. Hansen
- Department of Anaesthesiology & Intensive Care—Paediatric SectionOdense University Hospital Odense Denmark
- Department of Clinical Research—Anaesthesiology University of Southern Denmark Odense Denmark
| | - Wenche Bakken Børke
- Division of Emergencies and Critical Care Medicine Oslo University Hospital Rikshospitalet Oslo Norway
| | - Mika H. Isohanni
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Division of Anaesthesiology, Eye and Ear Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Albert 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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Incidence of peri-operative paediatric cardiac arrest and the influence of a specialised paediatric anaesthesia team. Eur J Anaesthesiol 2019; 36:55-63. [DOI: 10.1097/eja.0000000000000863] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Uffman JC, Tumin D, Beltran RJ, Tobias JD. Severe outcomes of pediatric perioperative adverse events occurring in operating rooms compared to off-site anesthetizing locations in the Wake Up Safe Database. Paediatr Anaesth 2019; 29:38-43. [PMID: 30447125 DOI: 10.1111/pan.13549] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/24/2018] [Accepted: 11/12/2018] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Joshua C Uffman
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ralph J Beltran
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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Engelhardt T, Ayansina D, Bell GT, Oshan V, Rutherford JS, Morton NS. Incidence of severe critical events in paediatric anaesthesia in the United Kingdom: secondary analysis of the anaesthesia practice in children observational trial (APRICOT study). Anaesthesia 2018; 74:300-311. [PMID: 30536369 DOI: 10.1111/anae.14520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2018] [Indexed: 12/20/2022]
Abstract
The anaesthesia practice in children observational trial of 31,127 patients in 261 European hospitals revealed a high (5.2%) incidence of severe critical events in the peri-operative period and wide variability in practice. A sub-analysis of the UK data was undertaken to investigate differences compared with the non-UK cohort in the incidence and nature of peri-operative severe critical events and to attempt to identify areas for quality improvement. In the UK cohort of 7040 paediatric patients from 43 hospitals, the overall incidence of peri-operative severe critical events was lower than in the non-UK cohort (3.3%, 95%CI: 2.9-3.8 vs. 5.8%, 95%CI: 5.5-6.1, RR 0.57, p < 0.001). There was a lower rate of bronchospasm (RR 0.22, 95%CI: 0.14-0.33; p < 0.001), stridor (RR 0.42, 95%CI: 0.28-0.65; p < 0.001) and cardiovascular instability (RR 0.69, 95%CI: 0.55-0.86; p = 0.001) than in the non-UK cohort. The proportion of sicker patients where less experienced teams were managing care was lower in the UK than in the non-UK cohort (10.4% vs. 20.4% of the ASA physical status 3 and 9% vs. 12.9% of the ASA physical status 4 patients). Differences in work-load between centres did not affect the incidence and outcomes of severe critical events when stratified for age and ASA physical status. The lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated paediatric anaesthesia providers managing the higher risk patients in the UK. Areas for quality improvement include: standardisation of serious critical event definitions; increased reporting; development of evidence-based protocols for management of serious critical events; development and rational use of paediatric peri-operative risk assessment scores; implementation of current best practice in provision of competent paediatric anaesthesia services in Europe; development of specific training in the management of severe peri-operative critical events; and implementation of systems for ensuring maintenance of skills.
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Affiliation(s)
- T Engelhardt
- Department of Anaesthesia, Royal Aberdeen Children's Hospital, Aberdeen, UK.,Institute of Education for Medical and Dental Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - D Ayansina
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - G T Bell
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, Scotland, UK
| | - V Oshan
- Department of Anaesthesia, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - J S Rutherford
- Designated Paediatric Anaesthetist, Dumfries and Galloway Royal Infirmary, Dumfries, Scotland, UK
| | - N S Morton
- Department of Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, Scotland, UK
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Feinstein MM, Pannunzio AE, Castro P. Frequency of medication error in pediatric anesthesia: A systematic review and meta-analytic estimate. Paediatr Anaesth 2018; 28:1071-1077. [PMID: 30375106 DOI: 10.1111/pan.13521] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 09/26/2018] [Accepted: 09/28/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical evidence shows that pediatric anesthesia patients are subject to a higher rate of life-threatening medical errors than their adult counterparts. Medication error in adult anesthesia is estimated to occur to 1 in 133 anesthetic administrations, but such a figure has not been determined for pediatric anesthesia patients. Individual studies of medication error in pediatric anesthesia have ranged from rates of 0.01% to 1.92% of anesthetic uses. The present study is a systematic review that employs a meta-analytic estimate to determine the rate of medication error in pediatric anesthesia. METHODS A systematic review of the literature on pediatric anesthesia medication error was conducted using Medline, Cochrane Database, PROSPERO, and Clinicaltrials.gov. A meta-analytic estimate was used to determine the medication error rate for all of the included studies. Subgroup sensitivity analysis was used to evaluate possible sources of heterogeneity in included studies. RESULTS Of the 433 initially screened records, 13 studies met inclusion criteria. Meta-analytic estimate of medication error rate across all studies was 0.08% (95% CI 0.05%-0.10%), or 1 out of 1250 anesthetics. Ten different countries were represented in the studies. Sample size of anesthetics reported on ranged from 296 to 2 316 635. Data collecting periods ranged from 3 months to 15 years. Six included studies individually reported higher rates of medication error in patients under 1 year of age. CONCLUSION The present systematic review revealed a medication error rate of 1 per 1250 anesthetic administrations in pediatric anesthesia. This result is significantly lower than would be expected given reported rates of medication error in adult anesthesia, which raises questions regarding the validity of research methods and reporting of medication error in pediatric anesthesia. Future investigations of medication error should employ methodologies other than self-reporting of error, such as retrospective chart review.
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Affiliation(s)
- Max M Feinstein
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Anthony E Pannunzio
- Department of Anesthesia, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pilar Castro
- Department of Pediatric Anesthesiology, Cleveland Clinic, Cleveland, Ohio
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Christensen RE, Lee AC, Gowen MS, Rettiganti MR, Deshpande JK, Morray JP. Pediatric Perioperative Cardiac Arrest, Death in the Off Hours. Anesth Analg 2018; 127:472-477. [DOI: 10.1213/ane.0000000000003398] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Becke K, Eich C, Höhne C, Jöhr M, Machotta A, Schreiber M, Sümpelmann R. Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA). Paediatr Anaesth 2018; 28:588-596. [PMID: 29851190 DOI: 10.1111/pan.13383] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 12/13/2022]
Abstract
Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.
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Affiliation(s)
- Karin Becke
- Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital/Hospital Hallerwiese, Nürnberg, Germany
| | - Christoph Eich
- Department of Anaesthesia, Paediatric Intensive Care and Emergency Medicine, Auf der Bult Children's Hospital, Hannover, Germany
| | - Claudia Höhne
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Martin Jöhr
- Department of Anaesthesia, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Machotta
- Department of Anaesthesiology, Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands
| | - Markus Schreiber
- Department of Anaesthesiology, University Hospital Ulm, Ulm, Germany
| | - Robert Sümpelmann
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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Incidence and risk factors of anaesthesia-related perioperative cardiac arrest. Eur J Anaesthesiol 2018; 35:266-272. [DOI: 10.1097/eja.0000000000000685] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Inhalational versus Intravenous Induction of Anesthesia in Children with a High Risk of Perioperative Respiratory Adverse Events: A Randomized Controlled Trial. Anesthesiology 2018; 128:1065-1074. [PMID: 29498948 DOI: 10.1097/aln.0000000000002152] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Limited evidence suggests that children have a lower incidence of perioperative respiratory adverse events when intravenous propofol is used compared with inhalational sevoflurane for the anesthesia induction. Limiting these events can improve recovery time as well as decreasing surgery waitlists and healthcare costs. This single center open-label randomized controlled trial assessed the impact of the anesthesia induction technique on the occurrence of perioperative respiratory adverse events in children at high risk of those events. METHODS Children (N = 300; 0 to 8 yr) with at least two clinically relevant risk factors for perioperative respiratory adverse events and deemed suitable for either technique of anesthesia induction were recruited and randomized to either intravenous propofol or inhalational sevoflurane. The primary outcome was the difference in the rate of occurrence of perioperative respiratory adverse events between children receiving intravenous induction and those receiving inhalation induction of anesthesia. RESULTS Children receiving intravenous propofol were significantly less likely to experience perioperative respiratory adverse events compared with those who received inhalational sevoflurane after adjusting for age, sex, American Society of Anesthesiologists physical status and weight (perioperative respiratory adverse event: 39/149 [26%] vs. 64/149 [43%], relative risk [RR]: 1.7, 95% CI: 1.2 to 2.3, P = 0.002, respiratory adverse events at induction: 16/149 [11%] vs. 47/149 [32%], RR: 3.06, 95% CI: 1.8 to 5. 2, P < 0.001). CONCLUSIONS Where clinically appropriate, anesthesiologists should consider using an intravenous propofol induction technique in children who are at high risk of experiencing perioperative respiratory adverse events. VISUAL ABSTRACT An online visual overview is available for this article at http://links.lww.com/ALN/B725.
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Cardiac Arrest in Children. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0215-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Lerman J. Time for a paradigm shift in paediatric anaesthesia in Europe. THE LANCET RESPIRATORY MEDICINE 2017; 5:365-367. [DOI: 10.1016/s2213-2600(17)30117-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 03/10/2017] [Indexed: 01/01/2023]
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Pediatric Cardiopulmonary Arrest in the Postanesthesia Care Unit, Rare but Preventable. Anesth Analg 2017; 124:1231-1236. [DOI: 10.1213/ane.0000000000001744] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Erb TO, von Ungern-Sternberg BS, Moll J, Frei FJ. Impact of high concentrations of sevoflurane on laryngeal reflex responses. Paediatr Anaesth 2017; 27:282-289. [PMID: 28181336 DOI: 10.1111/pan.13062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Exaggerated defensive upper airway reflexes, particularly laryngospasm, may cause hypoxemic damage, especially in children. General clinical experience suggests that laryngeal reflex responses are more common under light levels of anesthesia, and previous clinical studies have shown an inverse correlation between laryngeal responsiveness and depth of hypnosis. However, this seems to be less obvious in children anesthetized with sevoflurane. The aim of this study was to assess the impact of high concentrations of sevoflurane on laryngeal and respiratory reflex responses in spontaneously breathing children. Accordingly, we tested the hypothesis that laryngeal and respiratory reflex responses were completely suppressed in spontaneously breathing children when anesthetized with sevoflurane 4.7% (=MACED95Intubation ) as compared with sevoflurane 2.5% (=1 MAC). METHODS In this prospective observational study, we tested the hypothesis that the incidence of laryngospasm evoked by laryngeal stimulation is diminished under high concentrations of sevoflurane. Following Ethics approval, trial registration, and informed consent, 40 children (3-7 years) scheduled for elective surgery participated in the trial. All children received sevoflurane 2.5% (1 MAC) and 4.7% (ED95Intubation ) in random order with 5-min equilibration between the states. Under both conditions, distilled water was sprayed under bronchoscopic view onto the larynx. Potential laryngeal and respiratory reflex responses were assessed offline by a blinded reviewer. RESULTS Laryngospasm (episodes lasting >10 s) occurred in 12/38 (32%) of the patients anesthetized with sevoflurane 2.5%, vs 7/38 (18%) in those anesthetized with sevoflurane 4.7% (difference: OR 3.5; 95% CI [0.72-16.84], P = 0.18). All other reflex responses (coughing, expiration reflexes, and spasmodic panting) were infrequent and were similar among the examined concentrations. CONCLUSION Against our hypothesis, laryngospasm could still be observed in 18% of children under the higher concentration of sevoflurane (4.7%, ED95Intubation ).
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Affiliation(s)
- Thomas O Erb
- Department of Anesthesia, University of Basel Children's Hospital, Basel, Switzerland
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, WA, Australia.,School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia
| | - Jens Moll
- Department of Anesthesia, University of Basel Children's Hospital, Basel, Switzerland
| | - Franz J Frei
- Department of Anesthesia, University of Basel Children's Hospital, Basel, Switzerland
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