BACKGROUND: Severe anesthetic-related critical incident (SARCI) monitoring is an essential component of safe, quality anesthetic care. Predominantly retrospective data from low- and middle-income countries (LMICs) report higher incidence but similar types of SARCI compared to high-income countries (HIC). The aim of our study was to describe the baseline incidence of SARCI in a middle-income country (MIC) and to identify associated risk for SARCI. We hypothesized a higher incidence but similar types of SARCI and risks compared to HICs. METHODS: We performed a 14-day, prospective multicenter observational cohort study of pediatric patients (aged <16 years) undergoing surgery in government-funded hospitals in South Africa, a MIC, to determine perioperative outcomes. This analysis described the incidence and types of SARCI and associated perioperative cardiac arrests (POCAs). We used multivariable logistic regression analysis to identify risk factors independently associated with SARCI, including 7 a priori variables and additional candidate variables based on their univariable performance. RESULTS: Two thousand and twenty-four patients were recruited from May 22 to August 22, 2017, at 43 hospitals. The mean age was 5.9 years (±standard deviation 4.2). A majority of patients during this 14-day period were American Society of Anesthesiologists (ASA) physical status I (66.4%) or presenting for minor surgery (54.9%). A specialist anesthesiologist managed 59% of cases. These patients were found to be significantly younger ( P < .001) and had higher ASA physical status ( P < .001). A total of 426 SARCI was documented in 322 of 2024 patients, an overall incidence of 15.9% (95% confidence interval [CI], 14.4–17.6). The most common event was respiratory (214 of 426; 50.2%) with an incidence of 8.5% (95% CI, 7.4–9.8). Six children (0.3%; 95% CI, 0.1–0.6) had a POCA, of whom 4 died in hospital. Risks independently associated with a SARCI were age (adjusted odds ratio [aOR] = 0.95; CI, 0.92–0.98; P = .004), increasing ASA physical status (aOR = 1.85, 1,74, and 2.73 for ASA II, ASA III, and ASA IV–V physical status, respectively), urgent/emergent surgery (aOR = 1.35, 95% CI, 1.02–1.78; P = .036), preoperative respiratory infection (aOR = 2.47, 95% CI, 1.64–3.73; P < .001), chronic respiratory comorbidity (aOR = 1.75, 95% CI, 1.10–2.79; P = .018), severity of surgery (intermediate surgery aOR = 1.84, 95% CI, 1.39–2.45; P < .001), and level of hospital (first-level hospitals aOR = 2.81, 95% CI, 1.60–4.93; P < .001). CONCLUSIONS: The incidence of SARCI in South Africa was 3 times greater than in HICs, and an associated POCA was 10 times more common. The risk factors associated with SARCI may assist with targeted interventions to improve safety and to triage children to the optimal level of care.
Summary Aim This study aimed to quantify the incidence of anesthesia‐related and perioperative mortality at a large tertiary pediatric hospital in South Africa. Methods This study included all children aged <18 years who died prior to discharge from hospital and within 30 days of their last anesthetic at the Red Cross War Memorial Children's Hospital between January 1, 2015 to December 31, 2015. A panel of three senior anesthetists reviewed each death to reach a consensus as to whether: (i) anesthesia caused the death; (ii) anesthesia may have contributed to or influenced the timing of death; or (iii) anesthesia was entirely unrelated to the death. Results There were 47 deaths within 30 days of anesthesia prior to discharge from hospital during this 12‐month period. The in‐hospital mortality within 24 h of administration of anesthesia was 16.5 per 10 000 cases (95% confidence intervals [CI]=7.8‐25.1) and within 30 days of administration of anesthesia was 55.3 per 10 000 cases (95% CI=39.5‐71.2). Age under 1 year (OR 4.5; 95% CI=2.5‐8.0, P =.012) and cardiac surgery and interventional cardiology procedures (OR 2.5; 95% CI=1.2‐5.2, P <.01) were both independent predictors of increased risk of perioperative mortality. Conclusion The overall 24‐h and 30‐day anesthesia‐related and in‐hospital perioperative mortality rates in our study are comparable with other similar studies from tertiary pediatric centers.
Abstract The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome sets for infants, children, and young people that are tailored to the priorities of the pediatric surgical population. Focusing on four age‐dependent patient subpopulations determined a priori for core outcome set development: (a) neonates and former preterm infants (up to 60 weeks postmenstrual age); (b) infants (>60 weeks postmenstrual age—<1 year); (c) toddlers and school age children (>1‐<13 years); and (d) adolescents (>13‐<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age‐dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across predetermined age‐groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children, and adolescents. Clinical indicators, particularly cardiorespiratory or medication‐related adverse events, were the most common outcomes for neonates and infants <60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under‐represented in perioperative trials. Patient‐centered outcomes, healthcare utilization, and bleeding/transfusion‐related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the postanesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient‐centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age‐specific group.
Pulmonary hypertension (PH) secondary to obstructive sleep apnea (OSA) is an uncommon but serious perioperative risk factor in children undergoing surgery for adenotonsillar hypertrophy. Routine pre-operative echocardiography is commonly requested if severe OSA is suspected. We investigated the incidence of PH in children with suspected OSA and explored the association between PH and OSA severity. A prospective study of children aged 1–13 years with suspected OSA admitted for overnight oximetry (OO) and echocardiography at a pediatric referral hospital in Cape Town, South Africa from 2018 to 2019. OSA severity was defined by McGill Oximetry Score (MOS): MOS 1–2 (mild-moderate) and MOS 3–4 (severe). PH was defined as mean pulmonary arterial pressure (mPAP) ≥20 mmHg estimated on echocardiographic criteria. Children with congenital heart disease, underlying cardio-respiratory or genetic disorders, and severe obesity were excluded. One hundred and seventy children median age 3.8 years (IQR 2.7–6.4) were enrolled and 103 (60%) were female. Twenty-two (14%) had a BMIz >1.0 and 99 (59%) had tonsillar enlargement grade 3/4. One hundred and twenty-two (71%) and 48 (28%) children had mild-moderate and severe OSA, respectively. Echocardiographic assessment for PH was successful in 160 (94%) children of which eight (5%) had PH with mPAP 20.8 mmHg (SD 0.9): six with mild-moderate OSA and two with severe OSA. No significant difference in mPAP and other echocardiographic indices was observed in children with mild-moderate (16.1 mmHg; SD 2.4) and severe OSA (15.7 mmHg; SD 2.1). Similarly, no clinical and OSA severity differences were observed in children with and without PH. PH is uncommon in children with uncomplicated OSA and there is no association of PH with severity of OSA measured by OO. Routine echocardiographic screening for PH in children with clinical symptoms of OSA without co-morbidity is unwarranted.
Abstract Background The prevalence of anemia in the South African pediatric surgical population is unknown. Anemia may be associated with increased postoperative complications. We are unaware of studies documenting these findings in patients in low‐ and middle‐income countries (LMICs). Aim The primary aim of this study was to describe the association between preoperative anemia and 26 defined postoperative complications, in noncardiac pediatric surgical patients. Secondary aims included describing the prevalence of anemia and risk factors for intraoperative blood transfusion. Method This was a secondary analysis of the South African Paediatric Surgical Outcomes Study, a prospective, observational surgical outcomes study. Inclusion criteria were all consecutive patients aged between 6 months and <16 years, presenting to participating centers during the study period who underwent elective and nonelective noncardiac surgery and had a preoperative hemoglobin recorded. Exclusion criteria were patients aged <6 months, undergoing cardiac surgery, or without a preoperative Hb recorded. To determine whether an independent association existed between preoperative anemia and postoperative complications, a hierarchical stepwise logistic regression was conducted. Results There were 1094 eligible patients. In children in whom a preoperative Hb was recorded 46.2% had preoperative anemia. Preoperative anemia was independently associated with an increased risk of any postoperative complication (odds ratio 2.0, 95% confidence interval: 1.3‐3.1, P = .002). Preoperative anemia (odds ratio 3.6, 95% confidence interval: 1.8‐7.1, P < .001) was an independent predictor of intraoperative blood transfusion. Conclusion Preoperative anemia had a high prevalence in a LMIC and was associated with increased postoperative complications. The main limitation of our study is the ability to generalize the results to the wider pediatric surgical population, as these findings only relate to children in whom a preoperative Hb was recorded. Prospective studies are required to determine whether correction of preoperative anemia reduces morbidity and mortality in children undergoing noncardiac surgery.
Advances in paediatric anaesthesia include the availability of dedicated facilities with appropriate equipment, monitoring and specialised personnel trained in paediatric anaesthesia and resuscitation. These developments have contributed to the reduction in perioperative risk for paediatric patients. However, access to all the resources available in dedicated paediatric facilities is limited in resource-constrained settings. The objective of this review is to provide guidance with regard to the selection of suitable facilities for perioperative care, risk stratification and patient selection, safe selection of medication and standardisation of its use, and implementation of specific anaesthetic techniques that can minimise risk in the paediatric surgical population.
Background: Safe and affordable anaesthesia and surgery is a public health imperative. There are few data describing care provision and outcomes for children undergoing anaesthesia and surgery in Africa. Methods: International 14-day prospective, observational cohort study of children (<18 years) undergoing surgery in African countries. We aimed to recruit as many hospitals as possible across all levels of care providing surgical treatment for children. Each hospital recruited all eligible children for a 14-day period between January 2022 and December 2022. The primary outcome was in-hospital postoperative complications within 30 days of surgery. The secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities and procedures considered necessary for safe surgical care of children. Findings: We recruited 8625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (4.9) years, and 5675/8600 children (66%) were male. Most children were healthy (American Society of Anesthesiologists’ Class I, 6110/8579 children [71%]). 5325/8604 (62%) of children underwent elective surgery. Postoperative complications occurred in 1532/8515 (18·3%) of children. There were 199/8596 deaths (2·3%) following surgery. Deaths following postoperative complications occurred in 166 of 1530 complications (10·8%). Operating rooms were reported as safe for anaesthesia and surgery for neonates, infants, and children <6 years in 121/223 (54·3%), 147/223 (65·9%), and 188/223 (84·3%) of hospitals. 48/221 (22%) of hospitals did not have reliable electricity, and 42/221 (19%) did not have a reliable oxygen supply. Interpretation: Outcomes following anaesthesia and surgery for children in Africa are poor. Complication and mortality rates are fourfold and 11-fold higher respectively than high-income countries. To improve surgical outcomes for children in Africa, we need health system strengthening, provision of environments which are safe for the conduct of anaesthesia and surgery, and strategies to address the high rate of ‘failure to rescue’. Trial Registration: This study was registered on ClinicalTrials.gov (NCT05061407).Funding: Jan Pretorius Research Fund of the South African Society of Anaesthesiologists (SASA)Association of Anesthesiologists of Uganda.Declaration of Interest: This study was funded by Jan Pretorius Research Fund of the South African Society of Anaesthesiologists (SASA) and Association of Anesthesiologists of Uganda. The funders had no role in the study design, data collection, data analysis, data interpretation, or writing of the paper. Ethical Approval: Research ethics and regulatory approvals were in place before starting the study at each site, in accordance with their national research regulations. The primary ethics approval was from the Health Research Ethics Committee of the Faculty of Health Sciences, University of Cape Town (HREC 466/2021). The study was undertaken as an international clinical audit with no significant risk to the study population. We expected that in most countries there would be no requirement for individual patient consent as all data were recorded as part of routine clinical care, and anonymised before being uploaded to the study database. This precedent had already been set in previous national and international studies of adults and children undergoing surgery in Africa and Europe. Only two ethics committees required informed consent, both in South Africa, affecting seven hospital sites. ‘Broadcasting’ signage, as an infographic poster with pictures and words, and as a poster with words only, were placed in participating hospitals to ensure that all patients and parents/guardians were aware that the hospital was participating in the study.
Dr Goobie is a Section Editor for Pediatric Anesthesia. Data sharing is not applicable to this article as no new data were created or analyzed in this study.
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