Complications Associated With the Anesthesia Transport of Pediatric Patients: An Analysis of the Wake Up Safe Database

Abstract

BACKGROUND: Transporting patients under anesthesia care incurs numerous potential risks, especially for those with critical illness. The purpose of this study is to identify and report all pediatric anesthesia transport-associated adverse events from a preexisting database of perioperative adverse events. METHODS: An extract of the Wake Up Safe database was obtained on December 14, 2017, and screened for anesthesia transport-associated complications. This was defined as events occurring during or immediately after transport or movement of a pediatric patient during or in proximity to their care by anesthesiologists, including repositioning and transfer to recovery or an inpatient unit, if the cause was noted to be associated with anesthesia or handover. Events were excluded if the narrative clearly states that an event was ongoing and not impacted by anesthesia transport, such as a patient who develops cardiac arrest that then requires emergent transfer to the operating room. The search methodology included specific existing data elements that indicate transport of the patient, handover or intensive care status preoperatively as well as a free-text search of the narrative for fragments of words indicating movement. Screened events were reviewed by 3 anesthesiologists for inclusion, and all data elements were extracted for analysis. RESULTS: Of 2971 events in the database extract, 63.8% met screening criteria and 5.0% (148 events) were related to transport. Events were primarily respiratory in nature. Nearly 40% of all reported events occurred in infants age ≤6 months. A total of 59.7% of events were at least somewhat preventable and 36.4% were associated with patient harm, usually temporary. Of the 86 reported cardiac arrests, 50 (58.1%) had respiratory causes, of which 74% related to anesthesia or perioperative team factors. Respiratory events occurred at all stages of care, with 21.4% during preoperative transport and 75.5% postoperatively. Ninety-three percent of unplanned extubations occurred in patients 6 months and younger. Ten medication events were noted, 2 of which resulted in cardiac arrest. Root causes in all events related primarily to provider and patient factors, with occasional references to verbal miscommunication. CONCLUSIONS: Five percent of reported pediatric anesthesia adverse events are associated with transport. Learning points highlight the risk of emergence from anesthesia during transport to recovery or intensive care unit (ICU). ICU patients undergoing anesthesia transport face risks relating to transitions in providers, equipment, sedation, and physical positioning. Sedation and neuromuscular blockade may be necessary for transport in some patients but has been associated with adverse events in others.

Complications associated with removal of airway devices under deep anesthesia in children: an analysis of the Wake Up Safe database

“…In adult patients, remifentanil demonstrated similar effects [21]. Though positioning patients laterally may help prevent adverse events [22,23], patient movement and position changes under inadequate anesthesia may provoke adverse events [11].…”

“…The registry's creation and data entry are described below. Each adverse event was prospectively defined using expert consensus prior to the launch of the database [11]. Adverse events selected for possible inclusion undergo local review by a panel of anesthesiologists trained in root cause analysis who determine the root causes and outcome of the event.…”

“…Events are then entered in the registry in a de-identified fashion [10]. Detailed descriptions of the database and database extract preparation for research purposes have been previously described [11]. Institutional Review Board approval for participation in this registry was obtained at all member sites, which deemed individual patient consent not required as all data are deidentified prior to upload to the database.…”

“…We extracted event data and variables using the same methodology as previous studies involving the Wake Up Safe database [11]. The etiology for respiratory events was determined from the event narrative field and specific database variables.…”

Hot Topics in Safety for Pediatric Anesthesia

“…There were 10 medication events and two of those resulted in cardiac arrest. Root causes were attributed to provider and patient factors and, occasionally, verbal miscommunication was referenced [31].…”