Improved outcomes in paediatric anaesthesia: contributing factors ...

Pediatr Surg Int (2012) 28:553–561 DOI 10.1007/s00383-012-3101-y

REVIEW ARTICLE

Improved outcomes in paediatric anaesthesia: contributing factors Mostafa Somri • Arnold G. Coran • Christopher Hadjittofi • Constantinos A. Parisinos • Jorge G. Mogilner • Igor Sukhotnik Luis Gaitini • Riad Tome • Ibrahim Matter

•

Accepted: 24 April 2012 / Published online: 12 May 2012 Springer-Verlag 2012

Abstract Purpose To discuss developments in paediatric anaesthesia and explore the factors which have contributed to improved anaesthetic-related patient outcomes. Methods Narrative review of findings in the literature retrieved from MEDLINE/Pubmed and manual search. Results Adverse perioperative outcomes related to anaesthesia have been extensively debated over the past few decades, with studies implicating factors such as major human error and equipment failure. Case series and event registries have enlightened physicians on sources of error and patient risk factors such as extremes of age, comorbidity and emergent circumstances. Anaesthetic-related deaths in children fell from 6.4 per 10,000 anaesthetics in the early 1950s to as M. Somri (&) L. Gaitini R. Tome Anesthesiology Department, Pediatric Anesthesia Unit, Bnai Zion Medical Center, Technion-Israel Institute of Technology, The Ruth and Bruce Rappaport Faculty of Medicine, P.O.B 4940, 31048 Haifa, Israel e-mail: [email protected] A. G. Coran Section of Pediatric Surgery, C.S. Mott Children’s Hospital, University of Michigan Medical School, ANN ARBOR, MI, USA C. Hadjittofi UCL Medical School, London, UK C. A. Parisinos Department of Acute Medicine, Royal Free Hospital, London, UK J. G. Mogilner I. Sukhotnik I. Matter Departments of General and Pediatric Surgery, Bnai Zion Medical Center, Technion-Israel Institute of Technology, The Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel

low as 0.1 per 10,000 anaesthetics by the end of the century. Advances in anaesthetic agents, techniques, monitoring technologies and training programmes in paediatric anaesthesia play a vital role in driving this downward trend. Conclusion Despite substantial progress, there is still much room for improvement in areas such as adverse-event reporting, anaesthetic-related risk and late neurocognitive outcomes. Systematic reviews comparing paediatric patient outcomes after neuroaxial block versus general anaesthesia are currently unavailable. The future of paediatric anaesthesia will most likely be influenced by much-needed large prospective studies, which can provide further insight into patient safety and service delivery. Keywords Anaesthesia Paediatric Surgery Outcome Mortality Risk

Introduction Anaesthesia-related adverse outcomes have been extensively debated over the past few decades. Landmark papers and statements have applied critical incident analysis techniques, borrowed from fields such as aviation, in order to examine the causes and consider possible preventative strategies for such outcomes (also termed ‘‘preventable mishaps’’). By highlighting how imperfections in clinical practice could lead to errors and thus patient harm, these innovative analyses provided anaesthetists with new insights based on which they could act to promote anaesthesia patient safety [1, 2]. Although this specific term was not used at the time, these analyses have brought significant changes in anaesthetic practice. The American Society of Anesthesiologists (ASA) was created in 1984, the Anesthesia Patient Safety Foundation

123

554

(APSF) was founded in 1985, and the Closed Claims Project was initiated in mid-1985 by the ASA Committee on Professional Liability (CPL). These institutions were involved in and focused on developing and implementing patient safety statements. Between 1985 and 1993, the CPL had evaluated a total of 2,400 closed anaesthesia malpractice claims in the paediatric and adult populations; 10 % of claims involved patients younger than 16 years of age. Respiratory events were found to be more common in paediatric than in adult claims (43 vs. 30 %), as well as mortality-related claims (50 vs. 35 %). Furthermore, anaesthetic care was judged less than appropriate in paediatric claims (54 vs. 44 %). Finally, an estimated 89 % of paediatric events could have been prevented by pulse oximetry or capnometry [3]. These findings fuelled the adoption of monitoring standards. In the following years, studies analysing anaesthesiarelated adverse outcomes implicated major human error and equipment failure amongst other factors. In addition, they described the contributions of novel anaesthetic agents and new practices for dealing with perioperative adverse events in paediatric surgery. Although these observations may not apply universally, they emphasise the importance of understanding, anticipating and dealing with perioperative adverse effects to improve patient management and thus paediatric anaesthesia outcomes. A major development in the field has been the recognition that paediatric patients should be cared for by paediatric anaesthetists or physicians who can demonstrate the equivalent in terms of specific experience. In this review, we highlight the evidence on adverse outcomes related to paediatric anaesthesia and discuss the factors influencing morbidity and mortality over the past few decades. In addition, we present important issues which may drive the future course of paediatric anaesthesia.

A historical overview of paediatric anaesthesia outcomes Epidemiological data on anaesthesia-related morbidity and mortality in children were largely investigated many years ago [4, 5]. Outcomes in anaesthetised children have improved over the past six decades, as reflected in a decreasing anaesthesia-related mortality rate from 6.4 deaths per 10,000 anaesthetics between 1948 and 1952 to 0.2–4 deaths per 10,000 anaesthetics in more recent French (1987), Canadian (1990) and American (2000) series [6–9]. Paediatric patients were found to carry a threefold increased risk of cardiac arrest and mortality when compared with adult patients. An ASA Physical Status (ASA-PS) classification score of 3 or 4 also carried more risk than an ASA-PS score of 1 or 2 [10]. The first documented anaesthesia-related death occurred in 1848

123

Pediatr Surg Int (2012) 28:553–561

and involved a healthy 15-year-old girl undergoing removal of chronically infected toenails. The exact mechanism of death, however, was unclear [11]. The replacement of ether by halothane in 1956 advanced paediatric anaesthesia into a new era [12]. More recently, newer inhalation agents such as sevoflurane have completely replaced halothane as the only agents for inhalational induction, since they have been associated with fewer cardiovascular adverse events in the paediatric population. Although general anaesthesia is still used as the criterion standard for most paediatric surgical procedures, regional anaesthesia has been introduced as an intra- and postoperative adjunct for pain control. The advantages include a reduced requirement of anaesthetic agents, quicker emergence, less agitation, less opioid analgesia and a shorter recovery time. A number of studies have shown that regional anaesthesia has a more favourable profile in terms of metabolic and autonomic responses, as well as neurobehavioural distress associated with neonatal surgical procedures [13, 14]. Spinal anaesthesia is being increasingly used as an alternative to general anaesthesia in children, and holds an important position in both infra- and supraumbilical paediatric surgery. Studies have recommended that spinal anaesthesia should be preferred to general anaesthesia under certain conditions and particularly when operating on premature infants [15, 16]. The goals of perioperative management include reducing perioperative morbidity, facilitating rehabilitation and improving long-term outcomes. However, as discussed below, the effects of regional anaesthesia and analgesia on long-term outcomes are still controversial.

Cardiac arrest and mortality in paediatric anaesthesia The incidence of cardiac arrest is a simple and commonly used index of anaesthetic care quality. In 1978, Smith examined the statistics provided by two American healthcare institutions, which reported no deaths in 37,000 cases of tonsillectomy and one anaesthesia-related death in 29,000 procedures of all types. In his study, he notes a decreasing anaesthetic mortality rate in the paediatric population over the previous 20 years [17]. In a study of 24,165 anaesthetics administered between 2000 and 2002 at a French paediatric teaching hospital, the overall adverse events rate was 79 per 1,000 anaesthetics. Respiratory events occurred in 3 % of patients and were more frequent in infants. Cardiac events were recorded in 0.4 % of patients, occurring mainly in children with ASAPS of 3–5. Only one death was recorded; however, this was not anaesthesia related [18]. In a more recent series of 15,253 anaesthetics performed at a Brazilian teaching hospital, cardiac arrests and deaths


occurred at a rate of 22.9 and 9.8 per 10,000 anaesthetics, respectively. Cardiac arrests were attributed to respiratory and medication-related events (71.5 and 28.5 %, respectively). Risk factors for cardiac arrest included neonates, infants, ASA-PS C 3, emergency surgery and the use of general anaesthesia [19]. The prevalence of childhood obesity has more than tripled in the last 30 years. Children presenting for elective surgical procedures are more likely to have pre-existing medical conditions such as type 2 diabetes mellitus, asthma, obstructive sleep apnoea, hyperlipidaemia, hypertension and cardiovascular disease when compared with their normal-weight counterparts [20–25]. A retrospective study of 1,133 children undergoing planned outpatient dental procedures under anaesthesia at an American children’s hospital showed that obese children were more likely to suffer respiratory complications than non-obese children, leading to arterial oxygen desaturation and unexpected hospitalisation (2 vs. 0.19 % in both situations). These findings suggest that identification and awareness of childhood obesity as a risk factor for perioperative complications is important for optimising anaesthetic management and outcomes [26]. In summary, it is clear that cases involving neonates, infants, patients with pre-existing conditions, emergency surgery and obesity require particular attention to minimise the occurrence of perioperative cardiac arrest and death.

Event registries Paediatric anaesthetists are frequently asked about anaesthetic-related risks. Unfortunately, few prospective controlled studies have examined the consequences of general anaesthesia in children, and these studies have yielded variable and controversial results [8]. Most discussions focus on cardiac arrest in the paediatric population, and whether this was directly related to anaesthesia, surgical complications or high-risk pre-existing conditions such as severe congenital heart disease. Some of the most well-known results were extracted from the Pediatric Perioperative Cardiac Arrest (POCA) Registry, which compiled data from nearly 80 North American institutions. These results were reported and discussed by Morray et al. (‘‘POCA I study’’) and subsequently by Bhananker et al. (‘‘POCA II study’’) [9, 27]. The POCA I study (1994–1997) reported 289 perioperative cardiac arrests, 52 % of which were anaesthesia related. The POCA II study (1998–2004) reported 397 perioperative cardiac arrests, 49 % of which were anaesthesia related. In 2007, Bhananker et al. also compared patient characteristics and causes of anaesthesia-related arrests between POCA I and II. These included anaesthesia-

555

related arrests in ASA-PS 1 patients (15 vs. 7 %), infants (55 vs. 38 %) and emergency cases (21 % in both studies). Causes were mainly cardiovascular (32 vs. 41 %), respiratory (20 vs. 27 %), medication related (37 vs. 18 %) and equipment related (7 vs. 5 %). Arrests usually followed one or more of the following events: bradycardia, arrhythmia, hypotension, oxygen desaturation (measured by pulse oximetry and abnormal end-tidal CO2) and cyanosis. The apparent decline in medication-related arrests was attributed to the gradual replacement of halothane by sevoflurane. However, and despite these developments, anaesthesia-related mortality rates in POCA I and II are similar (26 vs. 28 %). Cardiovascular causes represented a significant proportion in both studies and were mainly related to haemorrhagic hypovolaemia and post-transfusion hyperkalaemia in POCA II. The authors specifically recommended close attention to the anticipation, estimation and replacement of blood loss [9, 27]. In 1987, Tiret et al. carried out a prospective survey of anaesthesia-related mortality and morbidity in infants and children, in which they analysed a representative sample of 40,240 anaesthetics administered at 440 random institutions in France. The risk of major complications was found to be significantly higher in infants than in children under 15 years of age (4.3 per 1,000 vs. 0.5 per 1,000 anaesthetics). Accidents in infants were due to respiratory failure and mainly occurred during anaesthetic maintenance, whereas in children they were due to either respiratory or circulatory failure and were equally frequent during induction, maintenance, and recovery. Furthermore, complications occurred more frequently in patients with higher ASA-PS scores and a greater number of co-morbidities, and in those undergoing emergency procedures [7]. The Japanese Society of Anesthesiologists Committee on Operating Room Safety (JSACORS) has published several studies on anaesthesia-related mortality and morbidity since 1993. Kawashima et al. [28] summarised the 1999 results from 793,847 anaesthesias. Anaesthetic management was found to be responsible for 12 % of all cardiac arrests, 22.8 % of all critical incidents and 1.8 % of all deaths. The overall death rate was 7 per 10,000 anaesthetics and the death rate totally attributable to anaesthetic management was 0.1 per 10,000 anaesthetics. In summary, the important messages from event registry findings are: 1. 2.

3.

Infants are at increased risk of anaesthetic-related complications. Complications are more frequent in patients with higher ASA-PS scores, more co-morbidities and in emergency procedures. Respiratory events are the main contributors to complications.

123

556

4.


Medication-related cardiac arrests are declining due to sevoflurane use.

Factors leading to improved outcomes

Medication and standards of care Over the last two decades, halothane has been largely phased out in favour of sevoflurane. Compared to halothane, sevoflurane causes less depression of myocardial contractility and fewer bradyarrhythmias, thus causing fewer cardiac arrests in children [29–32]. Suxamethonium (succinylcholine) is known to cause severe side effects such as bradyarrhythmias, hyperkalaemia, rhabdomyolysis and malignant hyperthermia [33]. In 1993, anaesthetists in the USA received a directive from Sandoz Inc., the manufacturer of succinylcholine (Anectine), that the drug was contraindicated as a first choice muscle relaxant to facilitate endotracheal intubation in children and adolescents. This statement was based on several reports of succinylcholine-induced cardiac arrest and arrhythmia. After reconsideration, this contraindication was downgraded to a warning [34, 35]. A recent Cochrane review found succinylcholine to be clinically superior to rocuronium, since it creates better intubation conditions and is shorter acting [36]. However, muscle relaxants such as rocuronium and vecuronium are widely used today to facilitate intubation whilst avoiding the side effects of succinylcholine. An early study which examined more than 500,000 anaesthesias between 1948 and 1952 found an anaesthesiaattributed death rate of 1:1,560, many of which were caused by upper airway obstruction and/or severe hypoxia. Further analysis revealed that deaths occurred disproportionately more frequently when the long-acting muscle relaxant curare (d-tubocurarine) was used [6]. Tubocurarine has since been replaced by other competitive intermediate-acting neuromuscular junction blocking agents such as atracurium, vecuronium and rocuronium. In a more recent case–control study, Arbous et al. found that reversing muscle relaxants is very effective in decreasing the risk of 24-h postoperative death and coma, with an odds ratio of 0.101 [37]. Sugammadex, a new selective relaxant binding agent, can reverse neuromuscular block more rapidly than conventional anticholinesterases with fewer side effects. As such, it may create safer conditions for unexpected or difficult endotracheal intubation and for paediatric anaesthesia in general [38].

123

Minimal standards for anaesthesia and patient monitoring were published by the Harvard Medical School Department of Anaesthesia and the ASA 25 years ago, with subsequent revisions [39, 40]. Since then, they have served a crucial role in preventing hypoxic–ischemic injury. A recent retrospective analysis of 27,971 claims made by the Danish Patient Insurance Association found 1,256 files related to anaesthesia. Out of a total of 24 fatal cases, 3 involved children and were due to incorrect insertion of an epidural needle, failure to secure the airway and medication errors. The authors concluded that most of these deaths (including 2 child deaths) could have been prevented by addressing systems issues and professional practice standards through training, as well as by establishing protocols and guidelines for airway management and ventilation handling [41]. In their analysis of the ASA Closed Claims Project database, Cheney et al. found that the proportion of claims for death or permanent brain damage between 1975 and 2000 decreased from 39 to 27 %. Amongst these claims, the proportion of respiratory events decreased, whilst that of cardiovascular events increased. Although these changes were associated with the adoption of pulse oximetry and end-tidal CO2 monitoring, causality could not be established. The authors also suggested that factors such as improved training, use of safer drugs and an emphasis on patient safety may have also contributed to the overall decline in claims [42]. The paediatric anaesthesia team A landmark study in 1978 revealed that 82 % of preventable anaesthesia-related incidents involved human error [1]. In 1999, the American Academy of Pediatrics (AAP) issued guidelines describing essential components for the safe application of paediatric perioperative anaesthesia. Specifically, the guidelines require that anaesthetists should be accredited as fellows in paediatric anaesthesia or should be able to demonstrate an equivalent competence. Nursing and technical personnel should also be appropriately trained and experienced. Local hospital policies should categorise patients according to risk status and specify the minimum case volume required to maintain competence. Furthermore, specific perioperative management areas with the appropriate equipment and drugs should be arranged for paediatric patients [43]. These recommendations were partly supported by a study examining the effect of paediatric anaesthetists on the frequency of cardiac arrests in infants. The authors compared 2,310 patients overseen by a paediatric anaesthetist to 2,033 patients who were not. No cardiac arrests occurred in the first group, compared to four


(19.7 per 10,000 anaesthetics) in the second group. They therefore concluded that the involvement of paediatric anaesthetists in infant care may decrease morbidity [44]. In a more recent study, Marcus investigated 668 anaesthetic incidents (mostly airway and respiratory related) at Birmingham Children’s Hospital and found that human factors contributed to 42.5 % of incidents. The most common factors included errors in judgment (43 %), followed by failure to check, technical failures of skill, inexperience, inattention/distraction and finally communication issues. The author concluded that knowledge of these factors is important for changes in practice, which can lead to safety improvements [45]. Ecoffey emphasises that a paediatric anaesthetist along with a second physician or nurse anaesthetist should be present in the operating room for newborns. For infants and children, a nurse anaesthetist should accompany the paediatric anaesthetist during induction, recovery, extubation, major procedures and in cases involving high-risk patients [46]. In fact, a recent prospective study of 800 children by Mamie et al. [47] demonstrated that children who are not managed by a specialist paediatric anaesthetist carry a 1.7-fold risk of experiencing perioperative respiratory adverse events. In analysing the occurrence of bradycardia (a surrogate indicator of cardiovascular depression), Keenan et al. [48] found that it was more frequent in infants (vs. older children), as well as in infants with greater disease burden, longer surgery and in the absence of a paediatric anaesthetist. A risk factor analysis by Tait et al. demonstrated that children with active and recent upper respiratory tract infections (URTIs) were more likely to experience adverse perioperative respiratory events than those with no URTIs. They however concluded that with careful management, most of them can undergo elective procedures safely. Furthermore, the decision to anaesthetise should be individualised, taking into account the anaesthetist’s comfort with anaesthetising children with URTIs [49]. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report recommended that paediatric surgery and anaesthesia should not be occasional practice, since outcomes depend on experience. Furthermore, the report recommended that trainees in paediatric anaesthesia should be closely supervised and that no anaesthetic or surgical interventions should occur without consulting the appropriate consultants. The report also recognises that the concentration of paediatric cases in specialist centres can lead to deskilling in hospitals where children are first admitted. The appropriateness of paediatric transfers should be rigorously audited by regional paediatric specialist units. In discussing the implications of the NCEPOD report, Lunn [50] comments that children’s lists can be arranged in non-specialist hospitals to improve service delivery and outcome.

557

Although greater volumes of paediatric surgical activity have been associated with better outcomes, it can be logistically difficult to refer all paediatric surgical cases to centres with adequately experienced paediatric surgeons and anaesthetists [51, 52]. Despite a clear inverse relationship between complications in paediatric anaesthesia and the number of anaesthetics administered, determining a minimum case volume is difficult. Nevertheless, Auroy et al. [53, 54] recommend a minimum of 200 cases annually.

Anaesthetic technique A recent multi-centre prospective study of regional anaesthetic techniques in 47 institutions found an overall complication rate of 0.12 %. These complications were usually minor without sequelae. Central blocks (34 % of all regional anaesthetic procedures) carried a sixfold complication risk compared to peripheral blocks. The authors concluded that regional anaesthesia remains an excellent method for providing postoperative analgesia, and that anaesthetists should choose peripheral over central blocks wherever possible given their significantly superior safety profiles [55]. Surgical trauma activates the hypothalamic–pituitary– adrenal axis, inducing the release of catecholamines, cortisol and other stress hormones which cause tachycardia, hypertension, hypercoagulation, increased metabolism and suppression of immune function [56]. Although sympathetic nervous system activation can have detrimental effects on the cardiovascular system, protein metabolism and metabolic rates in children, the relationship between stress response and clinical outcome is still unclear and debatable [57, 58]. The capability to modulate the surgical stress response expands the concept of anaesthesia beyond the simple avoidance of injury to include the provision of benefit. Neuroaxial blockade is particularly effective in altering the stress responses induced during major surgery. Regional anaesthetic techniques are also safe and effective in paediatric cardiac surgery. The benefits of neuroaxial blockade arise from altered coagulation, increased blood flow, an improved ability to breathe painlessly and reduction of the surgical stress response. A systematic review by Rogers et al. [59–62] confirmed the benefits of neuroaxial blockade with or without concomitant general anaesthesia in terms of reducing postoperative mortality and morbidity in the adult population. Epidural anaesthesia suppresses serum levels of stress hormones in children undergoing lower abdominal surgery, whereas general inhalational anaesthesia alone or general anaesthesia with low-dose intravenous opioids appears to be ineffective in suppressing the surgical stress response [63–65].

123

558

Preterm and formerly preterm infants undergoing general anaesthesia are at increased risk of perioperative respiratory and cardiovascular complications including apnoeic episodes [66]. As such, spinal anaesthesia is an increasingly popular technique in paediatric patients and especially in premature infants undergoing short surgical procedures. This technique has a positive impact on outcomes in terms of adverse postoperative cardiorespiratory events, particularly in high-risk infants. The benefits of spinal anaesthesia are particularly clear in the absence of inhalational or other sedative agents [67, 68]. The standard anaesthetic technique in neonates and small infants undergoing major gastrointestinal surgery is general anaesthesia with opioids as the main analgesic agents, or combined general and epidural anaesthesia for intra- and postoperative analgesia. Recent reports on the efficacy and safety of combined spinal-epidural anaesthesia (CSEA) in major abdominal surgery showed good results when patients were managed by paediatric anaesthetists. Spinal anaesthesia has a rapid onset, creating comfortable conditions for the performance of epidural anaesthesia, in which the epidural allows the continuation of surgical anaesthesia as well as extended postoperative analgesia [69, 70]. CSEA as well as thoracic epidural blockade can be used to avoid prolonged mechanical ventilation and its associated morbidity via improved diaphragmatic contractility, especially in high-risk premature infants [71]. CSEA also significantly decreases the incidence of postoperative cardiorespiratory adverse events in the neonatal intensive care unit, when compared with general anaesthesia in high-risk infants undergoing similar gastrointestinal procedures [72]. A recent randomised controlled study demonstrated that CSEA enables early recovery of intestinal function, reduces intra- and postoperative use of opioid analgesia and results in less frequent postoperative abdominal distension and pneumonia in infants compared to general anaesthesia [73]. However, there are no systematic reviews to demonstrate a difference in morbidity and mortality when performing neuroaxial block or general anaesthesia in the paediatric population.

Late neurocognitive outcomes Experimental studies have suggested that exposure to anaesthetic agents before the completion of synaptogenesis can lead to widespread neuronal apoptosis and late cognitive impairment in children. However, the applicability of these experimental findings to clinical settings, as well as the ‘‘window of vulnerability’’ and possibility of a dose– response relationship or threshold phenomenon are still subject to debate [74–77].

123


A literature review by Loepke and Soriano [78] revealed that exposure to anaesthesia can lead to short-term alterations in cognitive and behavioural function in young children. Long-term sequelae were more frequently reported in critically ill neonates, neonates or infants undergoing openheart surgery, and children with prenatal exposure to anaesthetics. However, the authors note that separating surgical stress response from anaesthetic effects can be difficult. In a retrospective pilot study, Kalkman et al. found that children who underwent urological surgery earlier than 2 years of age showed more behavioural disturbances than their older counterparts. Since the results did not reach statistical significance, the authors recommended a future study of at least 2,268 children to confirm or refute these findings and identified the need for prospective randomised studies [76]. Another retrospective study by Wilder et al. demonstrated that after adjusting for gestational age at birth, sex and birth weight, multiple (but not single) exposures to anaesthetics before 4 years of age were associated with an increased risk of developing learning disabilities [79]. Despite the growing body of evidence linking anaesthetic exposure to poor neurocognitive outcomes, large multi-centre randomised studies are required to minimise confounding factors and bias before any firm conclusions on causality are drawn [80]. For every medical or surgical intervention, the risks and benefits of proceeding with or withholding anaesthesia should be weighed on an individualised basis, in light of the best available evidence and according to patients’ and/or parents’ wishes.

Conclusion Over the past three decades, improved perioperative anaesthetic and surgical care have led to a declining trend in morbidity and mortality amongst the paediatric population. The compilation and analysis of event registries usually require a combination of large medical centres, ample resources and motivated individuals. Technological advances now permit easier and more time-efficient anaesthesia record-keeping and patient monitoring. Perhaps, the time has come for centralised electronic databases which can power large prospective studies to: • • • • •

examine the incidence of adverse events; determine risk factors for poor anaesthesia-related outcomes; evaluate the performance of systems and staff; produce local and regional morbidity and mortality statistics; audit local performance and outcomes against national and international standards in order to continuously


improve patient care and promote improvements in departmental structure, equipment and education. To achieve these aims, an environment which encourages voluntary, complete, confidential and objective reporting must be established, where accountability is balanced with system transparency and protection for reporters [81].

References 1. Cooper JB, Newbower RS, Long CD, McPeek B (1978) Preventable anesthesia mishaps: a study of human factors. Anesthesiology 49(6):399–406 2. Cheney FW, Posner K, Caplan RA, Ward RJ (1989) Standard of care and anesthesia liability. JAMA 261(11):1599–1603 3. Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW (1993) A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology 78(3):461–467 4. Rackow H, Salanitre E, Green LT (1961) Frequency of cardiac arrest associated with anesthesia in infants and children. Pediatrics 28:697–704 5. Graff TD, Phillips OC, Benson DW, Kelley E (1964) Baltimore Anesthesia Study Committee: factors in pediatric anesthesia mortality. Anesth Analg 43:407–414 6. Beecher HK, Todd DP (1954) A study of the deaths associated with anesthesia and surgery: based on a study of 599,548 anesthesias in ten institutions 1948–1952, inclusive. Ann Surg 1954(140):2–35 7. Tiret L, Nivoche Y, Hatton F, Desmonts JM, Vourc’h G (1988). Complications related to anaesthesia in infants and children. A prospective survey of 40240 anaesthetics. Br J Anaesth 61(3):263–269. doi:10.1093/bja/61.3.263 8. Cohen MM, Cameron CB, Duncan PG (1990) Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg 70:160–167 9. Morray JP, Geiduschek JM, Ramamoorthy C, Haberkern CM, Hackel A, Caplan RA, Domino KB, Posner K, Cheney FW (2000) Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology 93:6–14 10. Keenan RL, Bovan CP (1985) Cardiac arrest due to anesthesia: a study of incidence and causes. JAMA 253(16):2373–2377 11. Kalliardou E, Tsiotou AG, Velegrakis D, Avgerinopoulou A, Poulakou E, Papadimitriou L (2006) Historical aspects of inhalation anesthesia in children: ether and chloroform. Paediatr Anaesth 16:3–10 12. Fabian LW, Newton GW, Stephen CR (1958) Simple and accurate Fluothane vaporizer. Anesthesiology 19(2):284–287 13. Anand KJ, Ward-Platt MP (1988) Neonatal and pediatric stress responses to anesthesia and operation. Int Anesthesiol Clin 26(3):218–225 14. Kehlet H (1984) The stress response to anaesthesia and surgery: release mechanisms and modifying factors. Clin Anaesthesiol 2:314 15. Abajian JC, Mellish RW, Browne AF, Perkins FM, Lambert DH, Mazuzan JE Jr (1984) Spinal anesthesia for surgery in the highrisk infant. Anesth Analg 63(3):359–362 16. Tobias JD (2000) Spinal anesthesia in infants and children. Paediatric Anaesth 10(1):5–16

559 17. Smith RM (1978) Pediatric anesthesia in perspective. Sixteenth annual Baxter-Travenol Lecture. Anesth Analg 57(6):634–646 18. Murat I, Constant I, Maud’huy H (2004) Perioperative anaesthetic morbidity in children: a database of 24,165 anaesthetics over a 30-month period. Paediatr Anaesth 14(2):158–166 19. Gobbo Braz L, Braz JR, Mo´dolo NS, do Nascimento P, Brushi BA, Raquel de Carvalho L (2006) Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital. Paediatr Anaesth 16(8):860–866 20. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM (2004) Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002. JAMA 291(23):2847–2850 21. Bandla P, Brooks LJ, Trimarchi T, Helfaer M (2005) Obstructive sleep apnea syndrome in children. Anesthesiol Clin North Am 23(3):535–549 22. Sorof JM, Turner J, Martin DS, Garcia K, Garami Z, Alexandrov AV, Wan F, Portman RJ (2004) Cardiovascular risk factors and sequelae in hypertensive children identified by referral versus school-based screening. Hypertension 43(2):214–218 23. Friberg P, Allansdotter-Johnsson A, Ambring A, Ahl R, Arheden H, Framme J, Johansson A, Holmgren D, Wa˚hlander H, Ma˚rild S (2004) Increased left ventricular mass in obese adolescents. Eur Heart J 25(11):987–992 24. Hanevold C, Waller J, Daniels S, Portman R, Sorof J, International Pediatric Hypertension Association (2004) The effects of obesity, gender, and ethnic group on left ventricular hypertrophy and geometry in hypertensive children: a collaborative study of the International Pediatric Hypertension Association. Pediatrics 113(2):328–333 25. Mannino DM, Mott J, Ferdinands JM, Camargo CA, Friedman M, Greves HM, Redd SC (2006) Boys with high body masses have an increased risk of developing asthma: findings from the National Longitudinal Survey of Youth (NLSY). Int J Obes (Lond) 30(1):6–13 26. Setzer N, Saade E (2007) Childhood obesity and anesthetic morbidity. Paediatr Anaesth 17(4):321–326 27. Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, Campos JS, Morray JP (2007) Anesthesia-related cardiac arrest in children: update from the pediatric perioperative cardiac arrest registry. Anesth Analg 105:344–350 28. Kawashima Y, Seo N, Morita K, Irita K, Iwao Y, Tsuzaki K, Kobayashi T, Goto Y, Dohi S (2002) Anesthesia-related mortality and morbidity in Japan (1999). J Anesth 16:319–331 29. Sarner JB, Levine M, Davis PJ, Lerman J, Cook DR, Motoyama EK (1995) Clinical characteristics of sevoflurane in children. A comparison with halothane. Anesthesiology 82:38–46 30. Johannesson GP, Floreń M, Lindahl SG (1995) Sevoflurane for ENT-surgery in children. A comparison with halothane. Acta Anaesthesiol Scand 39:546–560 31. Holzman RS, van der Velde ME, Kaus SJ, Body SC, Colan SD, Sullivan LJ, Soriano SG (1996) Sevoflurane depresses myocardial contractility less than halothane during induction of anesthesia in children. Anesthesiology 85:1260–1267 32. Wodey E, Pladys P, Copin C, Lucas MM, Chaumont A, Carre P, Lelong B, Azzis O, Ecoffey C (1997) Comparative hemodynamic depression of sevoflurane versus halothane in infants: an echocardiographic study. Anesthesiology 87:795–800 33. Goudsouzian NG (1995) Recent changes in the package insert for succinylcholine chloride: should this drug be contraindicated for routine use in children and adolescents? (Summary of the discussions of the Anesthetic and Life Support Drug Advisory Meeting of the Food and Drug Administration, FDA building, Rockville, MD, June 9, 1994). Anesth Analg 80:207–208

123

560 34. Morell RC (1995) FDA group urges sux label reduced to ‘‘warning’’. J Clin Monit 11:141–143 35. Robinson AL, Jerwood DC, Stokes MA (1996) Routine suxamethonium in children. A regional survey of current usage. Anaesthesia 51:874–878 36. Perry JJ, Lee JS, Sillberg VA, Wells GA (2008) Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev 16(2):CD002788 37. Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw P, Werner FM, Grobbee DE (2005) Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 102:257–268 38. Meretoja OA (2010) Neuromuscular block and current treatment strategies for its reversal in children. Paediatr Anaesth 20:591–604 39. Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG (1986) Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 256:1017–1020 40. American Society of Anesthesiologists (2011) Standards for basic anesthetic monitoring. http://www.asahq.org/*/media/for% 20members/documents/standards%20guidelines%20stmts/basic %20anesthetic%20monitoring%202011.ashx. Accessed 25 Feb 2012 41. Hove LD, Steinmetz J, Christoffersen JK, Møller A, Nielsen J, Schmidt H (2007) Analysis of deaths related to anesthesia in the period 1996–2004 from closed claims registered by the Danish Patient Insurance Association. Anesthesiology 106:675–680 42. Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB (2006) Trends in anesthesia-related death and brain damage: a closed claims analysis. Anesthesiology 105:1081–1086 43. Hackel A, Badgwell JM, Binding RR, Dahm LS, Dunbar BS, Fischer CG, Geiduschek JM, Gunter JB, Gutierrez-Mazorra JF, Kain Z, Liu L, Means L, Meyer P, Morray JP, Polaner DM, Striker TW (1999) Guidelines for the pediatric perioperative anesthesia environment section on anesthesiology. Pediatrics 103:512–515 44. Keenan RL, Shapiro JH, Dawson K (1991) Frequency of anesthetic cardiac arrests in infants: effect of pediatric anesthesiologists. J Clin Anesth 3:433–437 45. Marcus R (2006) Human factors in pediatric anesthesia incidents. Paediatr Anaesth 16:242–250 46. Ecoffey C (2000) Paediatric perioperative anaesthesia environment. Curr Opin Anaesthesiol 13:313–315 47. Mamie C, Habre W, Delhumeau C, Argiroffo CB, Morabia A (2004) Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery. Paediatr Anaesth 14:218–224 48. Keenan RL, Shapiro JH, Kane FR, Simpson PM (1994) Bradycardia during anesthesia in infants. An epidemiologic study. Anesthesiology 80:976–982 49. Tait AR, Malviya S, Voepel-Lewis T, Munro HM, Siewert M, Pandit UA (2001) Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology 95:299–306 50. Lunn JN (1992) Implications of the national confidential enquiry into perioperative deaths for paediatric anaesthesia. Paediatr Anaesth 2:69–72 51. Borenstein SH, To T, Wajja A, Langer JC (2005) Effect of subspecialty training and volume on outcome after pediatric inguinal hernia repair. J Pediatr Surg 40:75–80 52. Surgical Advisory Panel. American Academy of Pediatrics (2002) Guidelines for referral to pediatric surgical specialists. Pediatrics 110:187–191 53. Auroy Y, Ecoffey C, Messiah A, Rouvier B (1997) Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics. Anesth Analg 84:234–235

123

Pediatr Surg Int (2012) 28:553–561 54. Stoddart PA, Brennan L, Hatch DJ, Bingham R (1994) Postal survey of paediatric practice and training among consultant anaesthetists in the UK. Br J Anaesth 73:559–563 55. Ecoffey C, Lacroix F, Giaufre´ E, Orliaguet G, Courre`ges P, Association des Anesthe´sistes Reánimateurs Pe´diatriques d’Expression Française (ADARPEF) (2010) Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF). Paediatr Anaesth 20:1061–1069 56. Liu S, Carpenter RL, Neal JM (1995) Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 82:1474–1506 57. Anand KJ, Hickey PR (1992) Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 326:1–9 58. Wu CL, Fleisher LA (2000) Outcomes research in regional anesthesia and analgesia. Anesth Analg 91:1232–1242 59. Kehlet H (1998) The modification of responses to surgery by neural blockade: clinical implications. In: Cousins MJ, Bridenbaugh PO (eds) Neural blockade in clinical anesthesia and management of pain, 3rd edn. Lippincott, Raven, Philadelphia, pp 145–188 60. Peterson KL, DeCampli WM, Pike NA, Robbins RC, Reitz BA (2000) A report of two hundred twenty cases of regional anesthesia in pediatric cardiac surgery. Anesth Analg 90:1014–1019 61. Hammer GB, Ngo K, Macario A (2000) A retrospective examination of regional plus general anesthesia in children undergoing open heart surgery. Anesth Analg 90:1020–1024 62. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S (2000) Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 321:1–12 63. Nakamura T, Takasaki M (1991) Metabolic and endocrine responses to surgery during caudal analgesia in children. Can J Anaesth 38:969–973 64. Somri M, Gaitini LA, Vaida SJ, Yanovski B, Sabo E, Levy N, Greenberg A, Liscinsky S, Zinder O (2002) Effect of ilioinguinal nerve block on the catecholamine plasma levels in orchidopexy: comparison with caudal epidural block. Paediatr Anaesth 12:791–797 65. Lacoumenta S, Paterson JL, Burrin J, Causon RC, Brown MJ, Hall GM (1986) Effects of two differing halothane concentrations on the metabolic and endocrine responses to surgery. Br J Anaesth 58:844–850 66. Kurth CD, Spitzer AR, Broennle AM, Downes JJ (1987) Postoperative apnea in preterm infants. Anesthesiology 66:483–488 67. Krane EJ, Haberkern CM, Jacobson LE (1995) Postoperative apnea, bradycardia, and oxygen desaturation in formerly premature infants: prospective comparison of spinal and general anesthesia. Anesth Analg 80:7–13 68. Somri M, Gaitini L, Vaida S, Collins G, Sabo E, Mogilner G (1998) Postoperative outcome in high-risk infants undergoing herniorrhaphy: comparison between spinal and general anaesthesia. Anaesthesia 53:762–766 69. Somri M, Tome R, Yanovski B, Asfandiarov E, Carmi N, Mogilner J, David B, Gaitini LA (2007) Combined spinal–epidural anesthesia in major abdominal surgery in high-risk neonates and infants. Paediatr Anaesth 17:1059–1065 70. Williams RK, McBride WJ, Abajian JC (1997) Combined spinal and epidural anaesthesia for major abdominal surgery in infants. Can J Anaesth 44:511–514 71. Manikian B, Cantineau JP, Bertrand M, Kieffer E, Sartene R, Viars P (1988) Improvement of diaphragmatic function by a thoracic extradural block after upper abdominal surgery. Anesthesiology 68:379–386

Pediatr Surg Int (2012) 28:553–561 72. Somri M, Coran AG, Mattar I, Teszler C, Shaoul R, Tomkins O, Tome R, Mogilner JG, Sukhotnik I, Gaitini L (2011) The postoperative occurrence of cardio-respiratory adverse events in small infants undergoing gastrointestinal surgery: a prospective comparison of general anesthesia and combined spinal–epidural anesthesia. Pediatr Surg Int 27:1173–1178 73. Somri M, Matter I, Parisinos CA, Shaoul R, Mogilner JG, Bader D, Asphandiarov E, Gaitini LA (2012) Comparing the effect of combined spinal–epidural anesthesia versus general anesthesia on the recovery time of intestinal function in young infants undergoing gastrointestinal surgery: a randomized, prospective controlled trial. J Clin Anesth (in press) 74. Anand KJ (2007) Anesthetic neurotoxicity in newborns: should we change clinical practice? Anesthesiology 107:2–4 75. Fredriksson A, Ponteń E, Gordh T, Eriksson P (2007) Neonatal exposure to a combination of N-methyl-D-aspartate and gammaaminobutyric acid type A receptor anesthetic agents potentiates apoptotic neurodegeneration and persistent behavioral deficits. Anesthesiology 107:427–436 76. Kalkman CJ, Peelen L, Moons KG, Veenhuizen M, Bruens M, Sinnema G, de Jong TP (2009) Behavior and development in

561

77.

78.

79.

80.

81.

children and age at the time of first anesthetic exposure. Anesthesiology 110:805–812 McGowan FX Jr, Davis PJ (2008) Anesthetic-related neurotoxicity in the developing infant: of mice, rats, monkeys and, possibly, humans. Anesth Analg 106:1599–1602 Loepke AW, Soriano SG (2008) An assessment of the effects of general anesthetics on developing brain structure and neurocognitive function. Anesth Analg 106:1681–1707 Wilder RT, Flick RP, Sprung J, Katusic SK, Barbaresi WJ, Mickelson C, Gleich SJ, Schroeder DR, Weaver AL, Warner DO (2009) Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology 110:796–804 Rappaport B, Mellon RD, Simone A, Woodcock J (2011) Defining safe use of anesthesia in children. N Engl J Med 364:1387–1390 Barach P, Small SD (2000) Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 230:759–763

123