Risk over time and risk factors of intraoperative respiratory events: a historical cohort study of 14,153 children

Abstract

BackgroundThe variation in the rate of intraoperative respiratory events (IRE) over time under anesthesia and the influence of anesthesia-related factors have not yet been described. The objectives of this study were to describe the risk over time and the risk factors for IRE in children at a tertiary care hospital in southern Thailand.MethodsThe surveillance anesthetic database and chart review of IRE of 14,153 children who received surgery at Songklanagarind Hospital during January 2005 to December 2011 were used to obtain demographic, surgical and anesthesia-related data. Incidence density of IRE per person-time was determined by a Poisson modelling. Risk of IRE over time was displayed using Kaplan Meier survival and Nelson-Aalen curves. Multivariate Cox regression was employed to identify independent predictors for IRE. Adjusted hazard ratios (HR) and their 95% confidence intervals (CI) were obtained from the final Cox model.ResultsOverall, IRE occurred in 315 out of 14,153 children. The number (%) of desaturation, wheezing or bronchospasm, laryngospasm, reintubation and upper airway obstruction were 235 (54%), 101 (23%), 75 (17%), 21 (5%) and 4 (1%) out of 315 IRE, respectively. The incidence density per 100,000 person-minutes of IRE at the induction period (61.3) was higher than that in the maintenance (13.7) and emergence periods (16.5) (p < 0.001). The risk of desaturation, wheezing and laryngospasm was highest during the first 15, 20 and 30 minutes of anesthesia, respectively. After adjusting for age, history of respiratory disease and American Society of Anesthesiologist (ASA) classification, anesthesia-related risk factors for laryngospasm were assisted ventilation via facemask (HR: 18.1, 95% CI: 6.4-51.4) or laryngeal mask airway (HR: 12.5, 95% CI: 4.6-33.9) compared to controlled ventilation via endotracheal tube (p < 0.001), and desflurane (HR: 11.0, 95% CI: 5.1-23.9) compared to sevoflurane anesthesia (p < 0.001).ConclusionsIRE risk was highest in the induction and early maintenance period. Assisted ventilation via facemask or LMA and desflurane anesthesia were anesthesia-related risk factors for laryngospasm. Therefore, anesthesiologists should pay more attention during the induction and early maintenance period especially when certain airway devices incorporated with assisted ventilation or desflurane are used.

Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center

“…Accordingly, only cardiac but not syndromic disease was identified as an independent risk factor for severe complications by multivariate logistic regression. Although we found a nonsignificant association with severe complications and higher ASA‐PS scores, the application of this risk assessment tool remains controversial in pediatric populations as there have been highly variable findings with other pediatric subpopulations . Only one further study has used the ASA‐PS score for the risk assessment in pediatric bronchoscopy, showing that children with ASA‐PS scores of I‐II had fewer unplanned events (18%) than children with scores of III (55.6%) .…”

“…Although we found a nonsignificant association with severe complications and higher ASA-PS scores, the application of this risk assessment tool remains controversial in pediatric populations as there have been highly variable findings with other pediatric subpopulations. [30][31][32] Only one further study has used the ASA-PS score for the risk assessment in pediatric bronchoscopy, showing that children with ASA-PS scores of I-II had fewer unplanned events (18%) than children with scores of III (55.6%). 21 Of note, children with scores of IV or V had even fewer adverse events (7.4%) in this analysis.…”

The effects of Anesthesia and opioids on the upper airway: A systematic review

“…Deep sedation and general anesthesia are known to increase the propensity for airway obstruction and collapse . This is generally a result of increased upper airway reflex sensitivity during anesthesia .…”

“…Deep sedation and general anesthesia are known to increase the propensity for airway obstruction and collapse. 62,63 This is generally a result of increased upper airway reflex sensitivity during anesthesia. 64 Contributors to these reflexes include: mechanical contact to the laryngeal airway, which induces reflex inhibition of breathing, coughing and bronchospasm; neural efferents from the pressure receptors in the wall of the upper airways, which form a neural loop; and stimulation of the superior laryngeal nerve, which results in glottic closure and laryngospasm.…”

Airway Complications during and after General Anesthesia: A Comparison, Systematic Review and Meta-Analysis of Using Flexible Laryngeal Mask Airways and Endotracheal Tubes

“…This finding is in close agreement with the findings of Dante Ranieri Junio et al [ 46 ]. However, some studies have found that the LMA has a higher risk of inducing laryngospasms than does ETT [ 41 , 47 , 48 ]. It has been speculated that this increased risk is caused by the use of the LMA or by accumulated secretions that may be a potent stimulus to the airway.…”