Pediatric Anesthesia Severe Adverse Events Leading to Anesthetic Morbidity and Mortality in a Tertiary Care Center in a Low- and Middle-Income Country: A 25-Year Audit

An update on the mechanisms and risk factors for anesthesia-related cardiac arrest in children: a narrative review

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42021229919.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

A retrospective cohort study.

SETTING

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

PATIENTS

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

MAIN OUTCOME MEASURES

Mortality rates.

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

None.

CLINICAL TRIAL NUMBER AND REGISTRY URL

NA.

Challenges of Pediatric Anesthesia Services and Training Infrastructure in Tertiary Care Teaching Institutions in Pakistan: A Perspective From the Province of Sindh

BACKGROUND

Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh.

METHODS

The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data.

RESULTS

Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria.

CONCLUSIONS

Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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