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

Abstract

Background: The analysis of adverse events, including morbidity and mortality (M&M), helps to identify subgroups of children at risk and to modify clinical practice. There are scant data available from low- and middle-income countries. Our aim was to estimate the proportion of pediatric patients with various severe adverse events in the perioperative period extending to 48 hours and to describe the clinical situations and causes of those events. METHODS: We reviewed the M&M database of the Department of Anesthesiology between 1992 and 2016. A data collection tool was developed, and the outcomes were standardized. Each case was reviewed independently and subsequently discussed between 2 reviewers to identify a major primary causative factor. RESULTS: The total number of pediatric cases during this period was 48,828. Seventy-six significant adverse events were identified in 39 patients (8 patients [95% confidence interval {CI}, 5.7–10.9] per 10,000). Thirteen patients had multisystem involvement, and hence the total number of events exceeded the number of patients. Respiratory events were the most common (33.5%). Thirteen patients had perioperative cardiac arrest within 48 hours of surgery (2.6 [95% CI, 1.3–4.3] per 10,000), 7 of these were infants (54%), 5 of whom had congenital heart disease (CHD). Eleven of these 39 patients died within 48 hours (2.0 [95% CI, 1.1–4.0] per 10,000). In 13 cases, anesthesia was assessed to be the predominant cause of morbidity (2.6 per 10,000), whereas in 26 cases, it contributed partially (5.32 per 10,000). There was only 1 death solely related to anesthesia (0.2 per 10,000), and this death occurred before the start of surgery. CONCLUSIONS: Adverse events were uncommon. Respiratory complications were the most frequent (33%). Infants, especially those with CHD, were identified as at a higher risk for perioperative cardiac arrest, but this association was not tested statistically. Twenty-eight percent of the patients who suffered events died within 48 hours. Increased access to anesthesia drugs and practice improvements resulted in a decline in perioperative cardiac arrests.

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

“…The finding that the overall incidence of SARCIs in our study was 3 times higher than in HICs and that respiratory events predominate was not unexpected. 1–5,9,11,15–17,25,26 Similar to other studies, we identified 4 independent risks associated with RCIs, those being younger age group, increasing ASA physical status, preoperative respiratory infection, and airway management with an ETT. 5,27 Despite high use of inhalational inductions in our study compared to von Ungern-Sternberg et al 27 (76% vs 39%), we did not identify inhalational induction, or otorhinolaryngology surgery (ENT) as independent risks associated with RCI.…”

“…Despite the differences in reported rates across country income categories, common themes emerge regarding types and risks for SARCIs. Perioperative respi-ratory critical incidents (RCIs) predominate, 1–5,9,11,15–17 while younger age, preexisting medical history (especially respiratory comorbidities), higher American Society of Anesthesiologists (ASA) physical status, 5 and emergency surgery are commonly identified risks for SARCIs. 3,5,16…”

“…[13][14][15] Despite the differences in reported rates across country income categories, common themes emerge regard ing types and risks for SARCIs. Perioperative respiratory critical incidents (RCIs) predominate, [1][2][3][4][5]9,11,[15][16][17] while younger age, preexisting medical history (especially respiratory comorbidities), higher American Society of Anesthesiologists (ASA) physical status, 5 and emergency surgery are commonly identified risks for SARCIs. 3,5,16 There are few prospective studies reporting pediatric perioperative outcomes and SARCIs from LMICs, including from Sub-Saharan Africa (SSA), an important cohort given that 42% of the SSA population are children <15 years.…”

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

“…The authors concluded that increased access to anesthetic drugs and practice improvements resulted in a decline in perioperative cardiac arrests. 15 Pediatric Anesthesia Training Infrastructure Assessment in any medical disciplines requires an infrastructure in terms of list numbers and available equipment and supervision, as well as elements of how the training is delivered, such as quality, content and frequency of lectures, workshops, case-based discussion, simulation training, clinical skills training, etc. Our survey focused only on the provision of infrastructure and not the quality.…”

Incidences and outcomes of intra-operative vs. postoperative paediatric cardiac arrest

“…1,11,15,16 The time-based definition of PPOCA differs among studies, ranging from cardiac arrests occurring in the postanaesthesia care unit (PACU) 3,5,10,12,16 -19 or 60 min after anesthesia 2,6 until 24 1,7,8,15 to 48 h after completion of anaesthesia. 13 However, settings for patient care and monitoring during anaesthesia and in the postoperative period such as the PACU, intensive care unit (ICU), and ward, are different in different locations. For example, in the operating room, continuous monitoring and the presence of anaesthesia providers at all times are considered the standard of care.…”