Incidence of severe critical events in paediatric anaesthesia in the United Kingdom: secondary analysis of the anaesthesia practice in children observational trial (APRICOT study)

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 perioperative 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.

The safety profile and effectiveness of propofol‐remifentanil mixtures for total intravenous anesthesia in children

“…The APRICOT study demonstrated an incidence of serious perioperative events of 5.2% of procedures, 12 which is much higher than our evaluation at 1.7%. However, a secondary analysis of the APRICOT data from the UK demonstrated a lower overall incidence of 3.3% 18 . Our evaluation differed from APRICOT, as patient numbers were much smaller and it did not cover the full spectrum of pediatric anesthetic practice.…”

“…However, a secondary analysis of the APRICOT data from the UK demonstrated a lower overall incidence of 3.3%. 18 Our evaluation differed from APRICOT, as patient numbers were much smaller and it did not cover the full spectrum of pediatric anesthetic practice. However, the commonest severe critical event reported in APRICOT was laryngospasm, which occurs in all aspects of pediatric anesthesia.…”

Training in pediatric anesthesia in Japan: how should we come along?

“…The APRICOT has also shown that senior anesthesiologists had 1% fewer critical respiratory events per year of experience and that facilities with a higher caseload had a lower rate of critical events [17]. A sub-analysis using the UK data only in the APRICOT demonstrated that the lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated pediatric anesthesia providers managing the higher-risk patients, whereas it did not show significant inverse volume-outcome effects in perioperative critical events among institutions [26]. Hence, controversies in volume-outcome association per anesthesia provider or per institution in terms of the incidence of perioperative adverse events exist.…”

“…The concept of "making every moment count" is important. Meanwhile, lack of experiences and clinical exposures may result in less independent practices and loss of self-confidence of anesthesiologist trainees, eventually leading to increasing perioperative complications and growing concerns over patient safety [17,25,26].…”

Outcomes after paediatric anaesthesia

“…Another major contributing factor affecting outcomes, frequently not considered, is the (in-) experience of anaesthesia care provider and subsequent clinical conduct of anaesthesia in these vulnerable patients [16,31,32]. Competent delivery of perioperative anaesthesia care in a suitably staffed environment may reduce the risk of occurrence of severe perioperative complications [33].…”