Chapter 127

Specific Considerations
VI
P A R T
127
CHAPTER
Mortality, Morbidity, and
Outcome in Pediatric Anesthesia
Isabelle Murat
The first recorded pediatric anesthetic death occurred in 1848,
within 2 years of the Ether Dome demonstration. Since that time,
anesthesia- related mortality and morbidity has considerably
decreased. Although mortality directly related to anesthesia is now
extremely low, the debate regarding both competence and qualification
of pediatric anesthesiologists remains an open question.
Indeed, the overall morbidity seems to be greater in infancy
compared to childhood or adulthood, and the experience of
anesthesiologist may contribute to further decrease the incidence
of undesirable anesthesia-related morbidity. With increasing safety
of anesthesia practice, outcome measures are now more directed
to patient comfort than to mortality and severe anesthesia-related
morbidity.
Sedation-related morbidity and mortality is discussed in
Chapter 56 and will not be considered in this review.
ANESTHESIA-RELATED
MORTALITY IN CHILDREN
Anesthesia-related mortality, defined as mortality totally or
partially related to anesthesia, is a rare event, and its incidence is
much lower than that of perioperative mortality. 1–7 Perioperative
mortality ranges between 7 and 70 per 10,000 anesthetics. However,
the wide ranges of perioperative mortality assessments from
1 to 30 days make any comparisons between countries difficult.
Anesthesia related mortality is currently 100 times lower than
perioperative mortality, ranging between 0.06 and 0.7 per 10,000
anesthetics in the available surveys (Table 127–1).
The incidence of anesthesia-related mortality is now much less
than 1/10,000 anesthetics in developed countries, and its frequency
has decreased dramatically over the last three decades. 8 In
the last French survey performed in 1999, the estimate rate
of deaths totally or partially related to anesthesia was 0.69 and
4.7, respectively, per 100,000 anesthetic procedures. 8 In comparison
with data from a previous nationwide French survey
(1978–1982), 7 the anesthesia-related mortality rate in France
seems to be reduced 10-fold in 1999. The latter is at least partly
related to the introduction of ventilatory monitoring (oximetry,
capnography) in clinical practice. 9–11
Similar trends were observed in pediatric anesthesia during
the last 30 years. At the Children’s Hospital in Boston, 12 the anesthetic
mortality was 1.8:10,000 in children 0–10 years of age from
1954 to 1966, and it decreased to 0.8:10,000 in the same age group
from 1966 to 1978. More recently, the National Confidential
Enquiry into Perioperative Deaths (NCEPOD) was conducted in
the United Kingdom in 1989, in order to evaluate the number of
deaths in children under 10 years of age during the first 30 days
after surgery. 13 Among the 417 deaths reported during the study
period, only 5 (1.2%) were totally attributable to anesthesia. In the
1999 French survey, the death rate totally or partially related to
anesthesia was 0.6 per 100,000 anesthetic procedures in children
aged 0–7 years and 1.2 per 100,000 anesthetic procedures in
children aged 8–15 years. 8
The presence of congenital heart disease was demonstrated to
add significant incremental risk of mortality in children requiring
inpatient noncardiovascular surgery. 14 This outcome difference is
present for both minor and major surgical procedures. However,
the database did not allowed to determine the actual cause death
and thus, the putative role of anesthesia.
INCIDENCE OF CARDIAC
ARRESTS IN CHILDREN
The incidence of anesthesia-related cardiac arrests has been
studied in different countries (Table 127–2). Regardless of the
study period or country, the incidence of cardiac arrest appears to
be much greater in infants of less than 1 year of age than in older
children or adults. 15–21 Similar results were reported in the
Australian Incident Monitoring Study, 22 in which the incidence of
cardiac arrests was 10 times greater in children less than 10 years

2092 PART 6 ■ Specific Considerations
TABLE 127-1. Perioperative Mortality and Anesthesia-Related Mortality in the Adult General Population in the
Published Surveys
Study Duration Number of Deaths per Anesthesia Mortality
Author Country Years of Survey Anesthesias 10,000 Anesthesia per 10,000
Holland 2
Holland 2
Tiret 7
Lunn
Hovi-Viander 3
Holland 2
Buck 1
Tikkanen 6
Lienhart 8
Kawashima 4
Australia
Australia
France
United
Kingdom
Finland
Australia
United
Kingdom
Finland
France
Japan
1960–1985
1960–1985
1978–1982
1978–1979
1975
1960–1985
1985–1986
1986
1999
1994–1998
–
–
24 h
6 d
72 h
–
30 d
72 h
>3d
7d
1960s
1970s
1980s
1990s
–
–
198,103
1,447,362
338,934
–
485,850
325,585
7,756,121
(estimated)
2,363,038
60–69
70–80
19
32
18
83–85
70
17
–
7.18
1.8
0.97
0.76
1.0
2.0
0.38
0.06
0.15
0.07
0.21
old compared to those older than 10. A Japanese survey of
preoperative morbidity and mortality during 2000 reported an
incidence of anesthesia-related cardiac arrest of 28.3 per 10,000
anesthetics in infants of less than 1 month of age and 8.5 in those
aged 1–12 months. 18
The etiology of anesthesia-related cardiac arrests has changed
over the past 20 years as practice has evolved in the care of patients.
In the 1980s–1990s, two major causes of cardiac arrests have been
identified in infants: respiratory problems and halothane overdose.
Both causes were at least partially avoidable. In 1985, Keenan 17
reported a survey of 27 cardiac arrests due to anesthesia. Six out of
27 were observed in children and all were considered avoidable.
One was related to ventilation failure and the other five to an
“absolute” halothane overdose. In the large database of Olsson
and Hallen, 20 the incidence of cardiac arrests was very high in
children less than 1 year of age (17/10.000 anesthesia). Ventilation
failure and halothane overdose were responsible for 66% of the
cases (33% and 33%, respectively), followed by vagal reflex (16%)
and hypovolemia (8%).
Keenan 23 addressed the question of incidence of cardiac arrests
and training in pediatric anesthesia. In infants less than 1 year of
age, the incidence of cardiac arrest was 19/10,000 anesthetics,
when anesthesia was provided by a nonpediatric anesthetist and
was zero when a pediatric anesthetist was in charge of the case. It
was concluded “that the use of pediatric anesthesiologists for
all infants 1 year of age or younger might decrease anesthetic
morbidity in this age group.”
The Pediatric Perioperative Cardiac Arrest registry (POCA)
started in 1994 and data are based on voluntary report from
63 university-affiliated or children’s hospitals in North America. The
first POCA (POCA 1) results found an incidence of 150 anesthesiarelated
cardiac arrests out of 1,089,200 anesthetics (1.4/10000). 24
By contrast with the pediatric component of the American
Society of Anesthesiologists (ASA) Closed Claims Project, 25
TABLE 127-2. Incidence of Cardiac Arrest During Anesthesia in Children
Cardiac Arrests
Author Country Years Number of Anesthesias Age, y per 10,000 Anesthesias
Olsson 20
Tiret 7
Cohen 15
Braz 16
Murat 19
Sweden
France
United States
Brazil
France
1967–1984
1978–1982
1982–1987
1996–2004
2000–2002
250,543
2,103
28,137
2,905
26,285
3,065
8,856
3,332
3,681
12,495
6,867

CHAPTER 127 ■ Mortality, Morbidity, and Outcome in Pediatric Anesthesia 2093
TABLE 127-3. Incidence of Cardiac Arrest According to
Physical Status, Age, and Emergency in the POCA Studies 24,26
POCA 1, 1994–1997, POCA 2, 1998–2004,
% (n = 289) % (n = 397)
ASA physical status:
1 15 7
2 18 18
4 37 42
5 27 28
2 6
Age:

2094 PART 6 ■ Specific Considerations
In addition to respiratory, medication, equipment, and cardiovascular
causes, cardiac arrests related to an occult underlying
disease have been reported. Unexpected cardiac arrests after
succinylcholine administration in infants and children with occult
myopathies are mainly related to hyperkaliemia. 30–33 Between 1990
and 1993, 25 unexpected cardiac arrests in apparently healthy
children scheduled for minor surgery were reported to the
Malignant Hyperthermia Association of the United States and the
North American Malignant Hyperthermia Registry. 30 Twelve
patients out of 25 had unrecognized myopathy (Duchenne dystrophy
in 8 and unspecified myopathy in 4). Restrictions on
succinylcholine use would have prevented 64% of arrests and 60%
of deaths. Surprisingly, no cardiac arrests resulting hyperkalemia
caused by rhabdomyolysis following the use of inhalation agents
and/or succinylcholine in children with undiagnosed myopathy
were reported in the two POCA registries. However, undiagnosed
myopathies remain a problem despite a reduced used of succinylcholine
after the Food and Drug Administration (FDA) warning
in 1994. Unexpected cardiac arrest related to rhabdomyolysis with
hyperkalemia have been reported after an uneventful anesthesia
without administration of succinylcholine in children with
unrecognized muscular dystrophy. 34–37 The dilemma of providing
anesthesia of the undiagnosed child was recently reviewed. 38,39
Basically there are two families of diseases that deserve consideration,
the muscular dystrophies and the mitochondrial
myopathies. As already discussed, it is commonly accepted to
avoid the use of succinylcholine and volatile agents in children
with known neuromuscular disorders, despite the risk of a patient
with neuromuscular disorder to have malignant hyperthermia
or rhabdomyolysis from exposure to a volatile anesthetic is
estimated to be less or equal to 1.09%. 40 Conversely, it is now
suggested that patients with known mitochondrial disease should
not receive propofol owing to the lipid carrier of propofol may
have adverse effect on fatty acid oxidation and mitochondrial
respiratory chain function, and therefore put patients with
mitochondrial disorders and closely related carnitine deficiency
syndromes at risk for a clinical scenario similar to propofol
infusion syndrome. 41–43
Cardiac arrests related to underlying undiagnosed cardiac
disease (viral myocarditis, long-QT syndrome, and abnormal
coronary artery) have also been reported in children. 44–46
To summarize old and recent data on incidence and etiologies
of pediatric cardiac arrests, one have to stress that the highest
incidence is still observed in infants of less than 1 year of age, in
emergency, in patients with cardiac diseases and other comorbidities.
There is a tendency for a relative reduction in respiratoryand
medication-related cardiac arrests together with a relative
increase in cardiovascular-related cardiac arrests. Finally equipment
is responsible for a stable proportion of such critical events.
The next challenge will be to reduce some avoidable causes of
cardiovascular cardiac arrests such as hyperkalemia following
massive transfusion and adequate compensation of acute hypovolemia,
and to anticipate carefully the management of children
with underlying known or unknown diseases.
ANESTHESIA-RELATED MORBIDITY
Incidence
Many studies have reported an increased morbidity in young
pediatric patients compared to older children and young adults.
TABLE 127-4. Risk Factors for Perioperative
Complications in Children 21
No.
Rate of Complications
Anesthesias (per 1000 Anesthesias) Significance
ASA Physical Status:
I 36,903 0.4 P < .001
II 1,461 3.4
III 518 11.6
IV, V 122 16.4
No. coexisting diseases:
0 36,544 0.5 P < .001
1 3,064 1.3
2 490 4.1
≥3 142 21.1
Previous anesthetic:
no 25,517 0.5 P < .05
yes 11,343 1.1
Duration of preoperative fasting, h:
8 34,067 0.6
Emergency:
no 33,391 0.5 P < .05
yes 5,918 1.5
Two large studies performed in the 1980s in France and Canada
reported a much higher incidence of severe complications in
infants compared to older children. 15,21 In the old French survey
performed in 1982, 21 the rate of perioperative complications
increased significantly with the young age, the ASA score, the
number of coexisting diseases, emergency, and reduced duration
of preoperative fasting (Table 127–4). In the Canadian survey 15
performed between 1982 and 1987, the incidence of major complications
was much higher in neonates (23.8%) than in infants
(5%) and older children (3%).
The most recent epidemiologic study on perioperative morbidity
was published by Murat, 19 and its results are summarized
in Table 127–5. Over a total of 24,165 general anesthesias performed
between January 2000 and June 2002, 724 incidents were
reported in the operating room (31/1000 anesthetics) and 1105 in
the postanesthetic intensive care (PACU) (48/1000 anesthetics).
In comparison with the study of Cohen published in 1990, 15 the
incidence of most complications has dramatically decreased. This
may at least partially be attributed to the availability of pulse
oximetry, capnography, the laryngeal mask airway, sevoflurane,
short-acting muscle relaxants and propofol, and by better training
and knowledge of pediatric anesthesiologists. For example, the
incidence of postoperative laryngospasm is nowadays lower by a
factor of more than 20.
However, the main messages remain the same:
The child less than 1 year of age is at increased risk
Respiratory problems are the cause of more than 50% of the
complications reported
There are more complications in the postanesthesia care unit
(PACU) but they are usually less severe than in the operating
room
The incidence of complications increases with the ASA score and
the number of coexisting problems

CHAPTER 127 ■ Mortality, Morbidity, and Outcome in Pediatric Anesthesia 2095
TABLE 127-5. Major Complications per 1000 Anesthesias Observed in the Operating Room (During Induction, Maintenance
or Awakening) or in the Postanesthesia Care Unit; Trousseau Hospital, Paris 19
Problems in the Operating Room
Problems in the Postanesthesia Care Unit
0–1 y 1–7 y 8–16 y 0–1 y 1–7 y 8–16 y
(n = 3,681) (n = 12,495) (n = 6,867) (n = 3,681) (n = 12,495) (n = 6,867)
Bronchospasm 5 2 0.5 1 0.8 0.7
Hypercapnia 2 0.8 0.1 1.3 0.4 1
Desaturation 15 7 3 5.7 2.7 2
Inhalation 0.5 0.3 0.5 0.2 0.4 0.4
Laryngospasm 4.6 2.3 1.3 0.2 0.4 0.5
Pulmonary edema 0 0 0.3 0.3 0.7 1
Respiratory depression – – – 3 1.3 1.4
Cardiac arrest 1 0.1 0.3 0 0 0
Bradycardia 3 0.7 1.4 0 0.08 0
Hypotension 1 0.4 1.6 0 0 0
Unexpected difficult intubation 2.4 0.5 0.8 – – –
Bronchial intubation 1.6 0.2 0.1 – – –
Cardiovascular Complications
Keenan conducted a retrospective study on the incidence of
bradycardia in 7959 children 0 to 4 year of age. 47 The authors
observed an increased incidence of bradycardia in infants of less
than 1 year of age compared to older infants, and the incidence
was decreasing with increasing age (Table 127–6). Halothane
overdose and hypoxia were, respectively responsible for 35% and
22% of bradycardia. The incidence of bradycardia was influenced
by ASA physical status, duration of surgery, emergency, as well as
qualification of anesthetist. Indeed, bradycardia was 2.5 times more
frequent in ASA 3 to 5 patients (vs ASA 1 to 2), and increased by
11% for each surgical hour. Conversely, bradycardia was lower by
a factor of 2 when a pediatric anesthetist compared to when a
nonpediatric anesthetist performed anesthesia. It should be kept
in mind that halothane was the main agent used during this study
period, oximetry and capnography were not routinely available,
and the author believes that incidence of bradycardia can no longer
be used as a marker for quality improvement of an anesthetic
department.
Many aspects of anesthesia have changed since publication of
Keenan’s study in 1994, such as drugs, monitoring, and equipment.
However, the number of cardiovascular critical incidents has not
decreased. Most of the recent studies highlight the role of
underlying disease, the physical status of the patient as well as the
major contribution of children with congenital heart disease. 26,28,48
A recent survey analyses incidents and complications during
cardiac catheterization in pediatric patients. 49 The overall incidence
of adverse events was 9.3% of the 4454 cardiac catheterizations
performed under general anesthesia. The event rate in infants
TABLE 127-6. Incidence of Bradycardia During
Anesthesia in Infants and Children, by Age 47
0–1 y 1–2 y 2–3 y 3–4 y
No. anesthesias 4645 1932 774 628
No. bradycardias 59 19 5 1
% bradycardias 1.27 0.98 0.65 0.16
under the age of 1 year was 13.9% compared with 6.7% for children
older than 1 year old. Among the 91 major complications,
61 involved the cardiovascular system and 22 of involved cardiac
arrest requiring cardiac compression.
Other cardiovascular causes of major complications are mainly
related to massive hemorrhage (with associated transfusion related
complications such as hyperkalemia), embolic events, and pulmonary
hypertension and are discussed in the POCA registry. 26 Most
of these events may be at least partly explained by the severity
of both patient condition and surgical procedure.
Respiratory Complications
Several studies have focused on the increased anesthesia-related
morbidity in children with a history of upper respiratory infection
(URI). 50–57 In 1988, DeSoto 51 observed that the incidence of oxygen
desaturation after anesthesia for ear, nose, and throat (ENT)
procedures was significantly increased in children with URI
compared to those without URI. Kinouchi 58 demonstrated that the
presence of an URI was an additional factor increasing the
susceptibility of small children to hypoxemia. Finally, Cohen 50
surveyed more than 20,000 anesthesia records and demonstrated
that the presence of URI increased anesthesia morbidity in
children. The risk of perioperative respiratory complications was
4 to 7 times higher in symptomatic children and 11 times higher
when a tracheal tube was used (Table 127–7). The children’s age,
physical status score, site of operation, and emergency status did
not explain this elevated risk.
TABLE 127-7. Factors Predicting an Adverse Respiratory
Event in Children 50 Relative Odds 95% Confidence Limits
Upper respiratory 8.94 6.04–13.22
infection (URI)
Intubation 5.21 4.21–6.46
Both URI and 11.13 6.84–18.10
intubation

2096 PART 6 ■ Specific Considerations
Two recent studies have reevaluated both the incidence of
respiratory complications and their risk factors. Bordet et al. 59
evaluated prospectively 1996 patients. One hundred fifty operations
were cancelled during the study period owing to ongoing
respiratory disease. The authors observed 157 respiratory complications
(7.9%). The mode of airway management influenced
the incidence of respiratory complications. The incidence was
10.2% with a laryngeal mask airway (LMA) (72/704), 4.7% with
facial mask (19/401) and 7.4% with a tracheal tube (66/891). Risk
factors for respiratory complications were: age

CHAPTER 127 ■ Mortality, Morbidity, and Outcome in Pediatric Anesthesia 2097
(10 mg/kg) reduces the incidence of postoperative apnea in former
preterm infants. 71
No recent study has reevaluated the risk of postoperative apnea
in former preterm infants anesthetized with modern anesthetic
agents. This deserves certainly further studies to update these old
guidelines.
Hyponatremias
Postoperative hyponatremia is the most frequent electrolyte
disorder in the postoperative period. Severe hyponatremia
(

2098 PART 6 ■ Specific Considerations
overdose, some may be reduced in the hands of skilled pediatric
anesthesiologists, such as respiratory complications, and some
may be avoided by careful preoperative screening such as
anaphylaxis to latex.
CLOSED CLAIMS STUDIES
The ASA Closed Claims Project was initiated in 1984 by the ASA
to identify major areas of anesthesia-related patient injury. Two
reviews of closed pediatric anesthesia malpractice claims have
been published so far. 10,25 Morray and colleagues 25 reviewed
pediatric and adult anesthesia closed malpractice claims from
1970 to the early 1980s. Among the 2400 claims instructed, 10% 238
involved pediatric patients. Most of the claims involved ASA PS
1 or 2 children. Twenty-eight percent of pediatric claims involved
infants younger than 1 year of age, and 55% children younger than
3 years. The incidence of claims for inadequate ventilation was
greater in children compared to adults (20% vs. 9%), the incidence
of unexplained cardiovascular events was also more frequent (6%
vs. 1%). Although not achieving statistical significance, trend
differences were also observed in airway obstruction, inadvertent
or premature extubation, and equipment problems. Respiratory
complications were more frequent in children when compared to
adults (43% vs 30%), mortality was higher (50% vs 35%) and more
complications were deemed avoidable by an adequate monitoring
(45% vs 30%). The cardiovascular causes of damaging events were
more frequent in children compared to adults, although most of
the children had no preexisting cardiovascular disease. Unexplained
cardiovascular collapse was observed in 6% of children
compared to 1% of adults, and might be related to the use of
halothane as the latter was the primary anesthetic in 74% of
children compared to only 19% in adults.
An update on pediatric closed claims reviewed 532 cases from
1973 to 2000. 10 From 1973 to 2000, there was a decrease in the
proportion of claims for death or brain damage and respiratory
events, particularly for inadequate ventilation/oxygenation (Table
127–8). However, claims for death (41%) and brain damage (21%)
remained the dominant injuries in pediatric anesthesia claims in
TABLE 127-8. Primary Damaging Events and Outcomes
of Pediatric Anesthesia Closed Malpractice Claims, as
Percentages per Decade 10 1970s 1980s 1990s
(n = 88) (n = 280) (n = 164)
Primary event:
Respiratory events 51 41 23
Cardiovascular events 19 18 26
Equipment 9 11 15
Medication 6 9 13
Other 2 9 16
None/unknown 13 12 7
Outcome:
Death/Permanent 78 75 62
Brain Damage
Other 22 25 38
Prevention: Better 63 41 16
monitoring would
prevent
the 1990s. Half of the claims in 1990–2000 involved patients were
3 years old or younger and one fifth were ASA PS 3 to 5. Cardiovascular
(26%) and respiratory (23%) events were the most
common damaging events. Although closed claims analysis has
many well-described limitations, the relative changes in the events
responsible for damaging events are consistent with the tendencies
reported in the two POCA studies 24,26 (i.e., a reduction in respiratory
events together with a relative increase in cardiovascular
events). The former may be attributable to prevention of inadequate
ventilation and oxygenation by capnography, pulse oximetry
and the introduction of the laryngeal mask airway. In the 1990s,
half of the unexplained cardiovascular events may have been
associated with cardiovascular depression from halothane, with
one third occurring in patients with unsuspected congenital or
acquired heart disease. Several preventable causes of patient injury
can be highlighted in this database. They include early detection
of bleeding and aspiration after adenotonsillectomy, prompt
recognition and treatment of blood loss in infants and the use of
appropriate doses of medication. The same preventable causes are
also pointed out in the two POCA studies, and this has to be
addressed to the pediatric anesthesiologist community.
MORTALITY AND MORBIDITY
OF REGIONAL ANESTHESIA
The number of claims and reported complications due to regional
anesthesia has increased in the adult literature, in parallel with the
increased use of these techniques. 98–100 Regional anesthesia techniques
have also been increasingly used in children during the last
two decades and have established themselves in pediatric anesthesia.
Although many complications have been occasionally
reported following virtually all peripheral or axial blocks procedures,
few data on the epidemiology and morbidity of regional
anesthesia are available in children.
Three large surveys, one retrospective and two prospective,
have been reported. 101–103 The retrospective American survey of
more than 150,000 caudal epidural anesthesia reported an esti -
mated incidence of major complications of 1:10,000. 102 Total spinal
anesthesia and hemodynamic or central nervous system (mainly
seizures) compromise likely related to inadvertent intravascular
injection were the most common. All were successfully managed.
More recently, the French-Language Society of Pediatric
Anesthesiologists (ADARPEF) conducted a 1-year prospective
study on the practice, incidents and accidents of regional
anesthesia in children. 101 In a 12-month period, 24,409 regional
blocks (out of 85,412 pediatric anesthetics) were recorded in 38
Belgian, Italian, and French institutions. The techniques used were
central neuraxial blocks (15,013; 61.5%), peripheral nerve blocks
(4090; 16.8%) and other techniques (5306; 21.7%). Among the
central neuraxial blocks, caudal anesthesia was the most common
procedure (12,111) followed by lumbar epidural (17,32) and spinal
anesthesia (506). Twenty-three complications were reported, with
an incidence of 0.7/1000 for caudal anesthesia, 4.2/1000 for
epidural anesthesia, and 2/1000 for spinal anesthesia. There were
no complications for peripheral nerve blocks. Eight dural
punctures were reported (resulting in four total spinal anesthesia),
six intravascular injections (two associated with seizures, two with
arrhythmia), two overdoses with arrhythmia, two transient
paresthesia, three technical problems and one opioids-related
apnea. All were successfully managed. The technique used was

CHAPTER 127 ■ Mortality, Morbidity, and Outcome in Pediatric Anesthesia 2099
deemed inappropriate by the experts involved in reviewing the
critical event in 11 out of the 23 complications. Adverse effects
occurred most frequently with very common procedures in
healthy patients.
The most recent data come from the United Kingdom and
provide the results of a prospective audit of nearly 11000 epidural
infusion analgesia between 2001 and 2005. 103 Data were collected
from 21 U.K. pediatric hospitals and analyzed by age (neonatal,
infants, children aged 1–8 years, children aged >8 years) and level
of insertion (thoracic 3846, lumbar 6226, caudal 921). All signi -
ficant critical clinical incidents were reviewed by a panel of experts.
These incidents were graded 1 to 3 according to severity and
classified either as attributable, or not, to the epidural. Patients with
complications were followed for up to 12 months. The expert panel
identified 96 “significant clinical incidents” (Table 127–9), of which
they attributed 56 to the epidural. Five incidents (1:2000) were
judged as the most serious (grade 1) and included epidural
abscesses (2), meningitis (1), postdural puncture headache requir -
ing 2 blood patches (1), and cauda equine syndrome (1). Only one
com plication persisted beyond 12 months (cauda equina syn -
drome). No serious incident was reported in the final 2 years of
the study. Nine incidents (1:1100) were graded as less serious
(grade 2) and included local anesthetic toxicity (1), nerve damage
(5), and drug errors (3). On the basis of this data, the overall rate
of complications associated with epidural catheters is approxi -
mately 1:200. However, most of these are concurrent events (1:250)
rather than directly related to the epidural itself. Interestingly,
analysis of the data suggests that there are fewer complications
related to post-operative management in institutions undertaking
the most epidurals (1000 epidurals: 1:3800).
The first closed claims 25 study included 238 pediatric patients
(out of a total of 2400 claims). A regional block was only used in
3% of children (7 out of 238) compared to 26% in adults. Unfortunately,
no details regarding the cause of claim are presented in
the report. No specific data are available in the second pediatric
closed claims analysis. 10
In the first POCA, 24 five cases of cardiac arrest were probably
related to intravascular injection of local anesthetics. Four
occurred during combined halothane and caudal anesthesia with
injection of bupivacaine with epinephrine despite negative test
TABLE 127-9. Clinical Incidents Reported in the National
Pediatric Epidural Audit on 10,633 Epidural Catheter
Techniques During 2001–2005 in the United Kingdom 103
All Clinical Incidents Attributable
Incidents Incidents to Epidural
Pressure sore 33 0
Infection 28 28
Drug error 14 13
Peripheral nerve injury 6 6
Post–dural puncture 6 6
headache
Compartment syndrome 4 0
Spinal cord insult 2 0
Spinal anesthesia 2 2
Local anesthetic toxicity 1 1
Total 96 56
dose and aspiration. All patients were successfully resuscitated
without injury. No data are available for the second POCA. In
the series of Murat 19 of 24,165 anesthetics, only two regional
anesthesia-related events were reported and were described as
failure of planned technique.
Peripheral nerve blocks are practiced more frequently than in
the older surveys discussed above. 104 As most of the complications
have been reported during central blocks, changes of regional
anesthesia related morbidity are expected but new complications
are likely to be described in the future. Other improvements such
as adapted pediatric equipment, ultrasound techniques and
availability of local anesthetics with reduced cardiovascular
toxicity are likely to result in further reduction of morbidity and
mortality in regional anesthesia.
OUTCOME OF ANESTHESIA
IN CHILDREN
Medical outcome might be defined as “a change in a patient’s
current and future health care.” 105 To the extent that cardiac arrest,
bradycardia, and perioperative respiratory complications are
considered an index of outcome, the latter are more frequent in
young infants and children, but most are deemed easily avoidable
in the hands of skilled practitioners. Conversely, coexisting disease,
emergency, duration of surgery, and poor clinical condition are
known risk factors of perioperative morbidity also described in
adults. However, it has been suggested 106 that measuring quality of
care in anesthesia by comparing major outcomes is unsatisfactory,
since the contribution of anesthesia to perioperative outcomes is
uncertain and the rate of major complications is too low. Therefore,
minor adverse events, particularly those of concern to the patient,
should be the focus for quality improvement in anesthesia. Indeed,
minor complications are frequently observed after minor surgery
usually performed in outpatients (Table 127–10). 107–109 The most
frequent complications are vomiting, cough, sleepiness, sore throat,
fever, and mild croup. In addition, residual pain is common even
after minor surgical procedures, and should be considered. 107
Predictors of occurrence of nausea and vomiting at home are the
presence of emetic symptoms in hospital, pain at home, age >5
years, and the use of postoperative opioids. These complications
usually resolve within 48 hours after surgery.
The next question is whether or not the choice of drug or
anesthesia technique would influence outcome. Most of the adult
studies have failed to demonstrate any outcome differences related
to anesthesia technique (regional vs general anesthesia) or to the
choice of drug after major surgery. 110–113 In neonates undergoing
cardiac surgery, Anand and coworkers 114 demonstrated that the
physiologic responses to stress are attenuated by deep anesthesia
(high-dose sufentanil followed by continuous opioid infusion)
compared to lighter anesthesia (halothane plus morphine) and
postoperative analgesia. In this particular study, deep anesthesia
continued postoperatively was associated with a reduced incidence
of postoperative morbidity (sepsis, metabolic acidosis, disseminated
intravascular coagulation) and mortality. It should be
emphasized that at the time this paper was published, high-dose
narcotic analgesia was already the gold standard for cardiac
surgery, thus limiting considerably the clinical relevance. Regional
anesthesia is usually combined with light general anesthesia in
children to allow the safe performance of the block on an immobile
patient. Only two pediatric studies have suggested beneficial
effects of epidural analgesia combined with light general

2100 PART 6 ■ Specific Considerations
TABLE 127-10. Incidence (%) of Postoperative Symptoms Following Day-Case Surgery in Children (n = 551) at Different
Observation Times After Discharge 107
Symptom In Hospital, % Same Day at Home, % Next Day, % Duration ≥2 days
Pain 17 56 37 19
Emetic symptoms 11 12 2 1
Vomiting 7 7 2 1
Sedation 39 77 37 9
Dizziness 10 16 1 1
Headache not determined 11 4 1
Difficulty in walking 5 17 6 3
anesthesia compared to standard general anesthesia after major
surgical procedures. 115,116 The need for postoperative ventilation
was significantly reduced in neonates receiving combined caudal
catheter and light general anesthesia compared to general anesthesia
alone following esophageal atresia repair. The use of an
epidural catheter reduced also postoperative morbidity and days
of oxygen therapy following fundoplication in children. In
addition, several small randomized studies have examined pain
scores and minor complications (e.g., nausea) and found benefits
from regional anesthesia for minor procedures. In ex–premature
infants scheduled for hernia repair, spinal anesthesia without
sedation is associated with less postoperative apnea than general
anesthesia or spinal anesthesia plus ketamine. 117 Therefore, in this
particular subgroup of patients, spinal anesthesia without sedation
has definitely some advantages over other anesthetic techniques
reducing postoperative morbidity.
Excitement upon recovery from anesthesia has been the subject
of many studies since the introduction of newer volatile agents
into clinical practice. An excellent review was recently published
on the subject, 118 highlighting the fact that there are more
questions than definite answer to this phenomenon of uncertain
etiology. Briefly, a variety of anesthesia-, surgery-, patient-, and
adjunct medication-related factors have been suggested to play a
role in the development of such an event. Possible etiological
factors include rapid emergence, intrinsic characteristics of an
anesthetic (mainly sevoflurane), postoperative pain, type of
surgery (ENT, eye surgery), young age (

CHAPTER 127 ■ Mortality, Morbidity, and Outcome in Pediatric Anesthesia 2101
TABLE 127-11. Examples of Anesthesia Risk Management Considerations 146
Risk Identification Risk Modification Risk Management
Patient
Practitioner
Practice
Underlying medical problems
Congenital anomalies
Anatomic abnormalities
Clinical competence
Appropriate training and experience
Impairment
Appropriate equipment
Standard of practice
Medical interventions
Surgical interventions
Supervision
Training
Treatment for impairment
Department policies and
procedures
Fund of knowledge
Appropriate informed consent
Preoperative assessment
Credentials
Continuing education
Fund of knowledge
“Drills” for rare events
Quality improvement monitoring
Continuous improvement
program
morbidity and mortality in pediatric anesthesia may be achieved
by improving several aspects of perioperative management:
●
●
●
●
●
●
Better preoperative evaluation of risk factors
Adequate monitoring and equipment and use of safer drugs
Optimizing perioperative fluid therapy
Training and continuous education
Human factors
Pediatric networking
Preoperative Evaluation Contributes
to Improved Safety of Anesthesia
The preoperative visit is the best opportunity to note foreseeable
anesthesia-related difficulties. 123 The major purpose and process of
the clinical interview is the exchange of information. It was de -
monstrated several years ago that a preadmission visit contributes
to a lessening of maternal anxiety during and after the child’s
hospitalization. 124,125 The preadmission visit was also associated
with a reduction in the incidence of negative post-hospital be -
havior, particularly in children aged 6 to 7 years. However, the
effects of a behavioral-based preoperative preparation program
vary with the child’s age, the timing of intervention, and any
history of previous hospitalization. 79,126 It has also been reported
that most American parents prefer to have comprehensive infor -
mation concerning their child’s perioperative period. 127 Detailed
anesthetic information regarding what might go wrong does not
increase parental anxiety and has the advantage of allowing
parents a fully informed choice. These studies emphasize the
importance of planning the preoperative visit several days before
surgery to give the parents enough time to understand what was
said. In France, the preoperative visit is mandatory and has to be
performed several days before surgery, but this is not the case in
most European and North American countries.
Most children scheduled for surgery are ASA physical status
1 or 2. One of the most common problems during the winter is
the high frequency of URI in young children. The presence of
an active URI increases the risk of perioperative respiratory
complications in children, as discussed previously. The risk/
benefit ratio of postponing elective surgery should be discussed
on an individual basis and recommendations have been proposed
by Cohen and colleagues 50 as follows: For children with asymptomatic
or mild URI, elective procedures should be postponed in
children younger than 1 year old. For children older than 1 and
younger than 5 years, the risk/benefit ratio of the surgical procedure
must be considered on an individual basis. Older children
are less at risk because of anatomically larger airways. Children
with significant preoperative symptoms of URI should have
their surgery postponed for 2 to 6 weeks following cessation of
symptoms. 128 However, canceling surgery at the last minute may be
emotionally unsettling, inconvenient and costly, and may have an
impact on the efficiency of the operating department. In an
American survey regarding the attitude of consultants facing a
child with an URI, 129 34.5% of the respondents reported that they
seldom (1–25% of the time) cancelled cases due to an URI, and
20.9% stated that they usually (76–99% of the time) cancelled in
the event of an URI. Factors that were considered most important
in making decision included the urgency of surgery and the
presence of asthma. This survey contradicts the traditional dogma
of routine cancellation and reflects the wide range of opinions and
approaches to this enduring clinical dilemma. In general, the
presence of an elevated temperature, cough, and chest signs indicative
of infection involving the lower respiratory tract should
prompt a postponement of elective surgery. Elective surgery that
is cancelled because of the presence of a lower respiratory tract
infection should not be rescheduled for at least 3-4 weeks to
minimize the risk associated with bronchial hyperreactivity.
Information on current and past medications should be
obtained. This should include the use of aspirin or other nonsteroidal
agents. Although there is no evidence that recent
immunization affects the outcome of anesthesia, some children
exhibit systemic toxic reactions to the vaccines that commonly
occur 2 to 3 days after diphtheria-tetanus-pertussis and hemophilus
influenza B vaccines but as late as 2 weeks after measlesmumps-rubella
vaccine. 130 In general, it is advisable to avoid
elective surgery during these periods. 131
Allergies to drugs and other substances should be noted.
Allergic or immediate reactions to natural latex have been reported
with increasing frequency since their first description in 1979. A
group of high-risk patients to latex anaphylaxis has been described.
This includes patients with spina bifida, bladder exstrophy, and
should be extended to all patients having multiple surgical
procedures, especially those operated in the neonatal period. 132–135
Susceptible patients should benefit from a “latex-free” environment
when surgery is planned. The role of preoperative visit is crucial to
identifying at-risk patients.
Information about difficulties or complications encountered in
previous anesthetic experiences should be obtained, especially
those related to intubation or respiratory or cardiovascular
compromise. Expected difficult intubation—common in some
congenital or acquired syndromes—should be planned and

2102 PART 6 ■ Specific Considerations
anticipated. 136,137 A history of postoperative nausea and vomiting
may influence the choice of anesthetic drugs. 138
Information regarding anesthetic-related complications such
as malignant hyperthermia or prolonged paralysis after an anesthetic
(pseudocholinesterase deficiency) is sought. A family
history of bleeding tendencies, muscular dystrophy, or drug use
is also significant.
During the preoperative visit, parents should be informed
regarding the anesthesia technique chosen and should give
informed consent when a regional technique is planned.
Progress in Equipment and Anesthesia
Drugs and Techniques
The checklist for the anesthesia machine required before starting
anesthesia reduces equipment-related incidents. 139,140 Pulse
oximetry and capnography are now routinely used in pediatric
anesthesia and contribute to a more rapid detection of hypoxia,
intubation-related problems, and ventilatory complications. 67,141
Although it has been suggested that appropriate monitoring
would decrease anesthesia-related morbidity, a large prospective
randomized study in 20,802 adult patients failed to demonstrate
any difference in postoperative morbidity and mortality when
pulse oximetry was available compared to the control group. 142,143
Only major complications were used in this study to assess the
benefits of pulse oximetry in terms of outcome. As anesthesia is
becoming safer, this outcome measure might require an extremely
high number of patients to statistically prove the benefits of pulse
oximetry in reducing severe anesthesia-related morbidity and
mortality. No outcome measures of pulse oximetry efficacy are
available for pediatric anesthesia. However, indirect evidence of
its efficacy is found in the POCA studies 26 in the reduction of
respiratory causes of cardiac arrests before and after the routine
use of pulse oximetry in the early 1990s. Another indirect
argument can be found in the updated pediatric closed claims
analysis. 10 It is suggested that the decrease in the proportion of
claims for pediatric death or brain damage may be related to the
increase in use of pulse oximetry and capnography. Indeed,
inadequate oxygenation and ventilation showed a dramatic
decrease from the 1970s (26%) compared to the 1990s (3%).
The introduction of new anesthetic drugs has also contributed
to decrease anesthesia-related morbidity and/or mortality in
children. The dramatic decline of medication-related cardiac
arrests in the second POCA study is possibly a result from the
decreased use of halothane in favor of the newer agents, particularly
sevoflurane. In the cases submitted to the POCA registry from
1994 to 1997, halothane was used in 51% and sevoflurane in 9%,
compared to 13% and 52%, respectively, of cases submitted from
1998 to 2004. Sevoflurane has a much safer hemodynamic profile
than halothane in healthy infants and children, 145,146 as well as in
those with cardiac compromise. 147,148 In addition to a decrease in
myocardial contractility, sevoflurane decreases the incidence of
bradycardia and arrhythmia during ENT 149 and dental surgery, 150 as
well as during endoscopies 151 compared with halothane.
The toxicity of bupivacaine when inadvertently injected into
the intravascular space is well recognized. 152 Incremental rather
than bolus injection has been advised for an earlier detection of an
intravascular injection. The replacement of bupivacaine with local
anesthetics with lower myocardial toxicity (ropivacaine and
levobupivacaine) may be safer, because cardiac arrests due to
inadvertent intravascular injection are more easily resuscitated
after ropivacaine than after bupivacaine. 153–155
Finally, the introduction of monitors of depth of anesthesia is
expected to reduce the incidence of awareness in clinical practice.
This has already been demonstrated in high-risk adult patients, 88
but pediatric data are lacking.
Perioperative Fluid Therapy
Should Be Optimized
There is now a large body of evidence that free intake of clear
fluids up to 2 to 3 hours preoperatively does not affect the pH
or volume of gastric contents at induction of anesthesia in infants,
children, or adults. 156,157 There is also evidence that infants aged
less than 3 months may safely be given infant formula (cow’s
milk) or breast milk up to 4 hours preoperatively. By contrast,
there is little evidence to support a reduction in the present 6-hour
fasting time for cow’s milk or solid food in older infants and
children. Parents of children allowed clear fluid up to 2 hours
preoperatively reported less difficulty in adhering to preoperative
feeding instructions, rated their children as less irritable, and
rated the overall perioperative experience as better than did
the parents of controls. Furthermore, when children inadvertently
ingested clear fluid within 2 hours of operation this resulted
in only moderate delays to surgery (30–60 min) and no can -
cellations.
However, perioperative fluid therapy during surgery and in the
early postoperative period remains a controversial issue. 76,158
During the 1980s, pediatric anesthesiologists were mainly concerned
with the risk of hypoglycemia during surgery and in the
perioperative period. However, the real risk of hypoglycemia has
been estimated at 0.5 to 2% in pediatric patients, apart from the
neonatal period. 159,160 This risk is likely to diminish, because
shorter preoperative fasting periods are now recommended.
Conversely, in the late 1980s, the danger of hyperglycemia in the
presence of neurologic brain damage was suspected in experimental
studies. 161 Thus, it should be recommended to avoid both
hypo- and hyperglycemia during the perioperative period. More
recently, the attention of anesthesiologists and pediatricians was
turned towards the incidence and risks of hyponatremia in
surgical and medical pediatric patients. 74,162–164 Because most fluid
deficit and perioperative losses consist of extracellular fluids, the
sodium content of hydrating solutions is of major importance
during surgery and in the early postoperative period. However, a
recent survey from the United Kingdom shows that more than
60% of anesthesiologists from the United Kingdom prescribe
hypotonic dextrose solutions in the intraoperative period, and
75% do so in the postoperative period. 165 Thus, it is time to change
these practices to avoid both hypo- and hyperglycemia and to
maintain normal sodium values within the perioperative period. 76
Such “golden compromise solution” has been available for more
than 15 years in most children’s hospitals in France. 75 It consists of
ready-to-use solution containing 0.9% glucose and 120 mmol/L
sodium.
Cardiac arrests from hypovolemia (usually secondary to
hemorrhage) and from the consequences of massive transfusion
(usually hyperkalemia) are considered anesthesia-related when
the anesthesiologist could possibly have prevented the arrest.
Failure by the anesthesiologist to secure adequate venous access
preoperatively, and failure to keep up with intraoperative blood

CHAPTER 127 ■ Mortality, Morbidity, and Outcome in Pediatric Anesthesia 2103
loss are the most common reasons why such arrests are deemed,
at least in part, anesthesia-related
Continuous Medical Education and
Regular Practice: The Most Important
Factors for Improving Patient Safety
Appropriate training, continuous education and extensive clinical
practice remain, certainly, the best means of reducing both
morbidity and mortality. 166–168
Initial training in pediatric anesthesia varies greatly from
country to country. Until recently, there was no recognition of
subspecialty care for pediatric patients despite the increasing
evidence of better outcome when anesthesia is performed by a
“pediatric anesthesiologist.” In February 1997, the American
Accreditation Council for Graduate Medical Education (ACGME)
recognized fellowship training in pediatric anesthesiology, the
latter becoming the 20th pediatric subspecialty to have accredited
fellowships. 169 European societies have also published guidelines
for training in pediatric anesthesia (available at: http://www.feapa.
org). However, initial education is only a part of the answer;
continuous medical education and expertise is at least as important
as initial education to provide safe care to children.
The most important point in providing safe care to children
is to avoid occasional pediatric practice. 170 After completion of
the NCEPOD, three main recommendations related to surgical
and anesthetic management were proposed to the U.K. medical
community:
1. Consultants who take the responsibility for the care of children
must keep up to date and stay competent in the management
of children.
2. Consultant supervision of trainees needs to be kept under
scrutiny. No trainee should undertake any anesthetic or surgical
operation on a child of any age without consultation with
their consultant.
3. Surgeons and anesthesiologists should not undertake “occaional
pediatric practice,” because the outcome was found to be
related to the experience of the clinicians involved.
To fulfill the third requirement, John Lunn 170 proposed an
annual minimal care load based on children’s age, consisting in
an annual workload of anesthetizing 12 infants younger than
6 months of age, 50 aged 6 months to 3 years, and 300 aged 3 to
10 years. Although these recommendations have been endorsed
by the British Pediatric Association, a postal survey 171 indicated
that, in 1994, only 17% of consultants in charge of anesthesia for
infants with pyloric stenosis met the level of continuing anesthetic
experience suggested by Lunn for a “children’s anesthetist,”
although 42% had a regular pediatric practice equivalent to at least
one list each week. The importance of sufficient practice to keep
on with skills and expertise had also been emphasized by the
results of a French postal survey. 98 The rate of reported anesthesia
complications was inversely related to the annual volume of
pediatric anesthetics: the lower the workload, the higher the
reported rate of complications. Indeed, a significantly higher
incidence of complications was reported by anesthesiologists
who performed 1 to 100 and 100 to 200 pediatric anesthetics
(respectively, 7.0 ± 24.8 and 2.8 ± 10.1 complications per 1000
anesthetics) than by those who administered more than 200
pediatric anesthetics per year (1.3 ± 4.3 per 1000 anesthetics).
These recommendations also apply to surgeons, since surgeryrelated
morbidity and mortality is lower in the hands of
experienced pediatric surgeons with regular practice compared to
those having an occasional practice. This has been demonstrated
for pediatric cardiac surgery, neurosurgery, appendectomies,
pyloric stenosis and pediatric intensive care. 172–179
The Human Factor
Anesthesia and the operating room environment is a complex
system involving man–machine and human–human interactions.
Human errors can be divided into active or latent errors. 180–182
Active errors are those occurring at the site of action, whereas
latent or system errors occur in the management, equipment
design, and staffing processes. Active errors can be further divided
into skill-based errors and mistakes. Skill-based errors (i.e., slips
and lapses), occur in very familiar tasks that we carry out without
much need for conscious attention. Mistakes are a more
complex type of error in which we do the wrong thing, believing
it to be correct. Rule-based mistakes occur when our behavior is
based on remembered rules and procedures. Knowledge-based
mistakes occur when the operator has to resort to an expert
judgment unsupported by rules and procedures. Violations are
deliberate deviations from rules, procedures, instructions, and
regulations.
In a retrospective review and analysis of anesthetic incidents
reported over a 2-year period (2002–2004) in a single children’s
hospital, Marcus 182 found that 284 out of the 668 incidents
reported from the 28023 anesthetics recorded were related to
human errors (Table 127–12). The most common were errors in
judgment (43%), failure to check (17.8%), technical failures of skill
(9.2%), inexperience (7.7%), inattention/distraction (5.6%) and
communication issues (5.6%). Knowledge of the causes of
incidents is necessary so that changes can be made in practice both
by individuals and department of anesthesia to make anesthesia as
safe as possible.
Besides the analysis of human errors, anesthesia management
itself may contribute to reduced anesthesia-related morbidity. In a
case–control study, Arbous et al. 139 demonstrated that human
resources are essential to reduce anesthesia-related mortality and
morbidity in adults. Indeed, the anesthesia management factors
that were associated with a decreased risk were a directly available
anesthesiologist, no change of anesthesiologist during anesthesia,
presence of a full-time working nurse, and two persons present
at emergence.
Pediatric Care Network Should be Organized
Given that experience, practice, and continuous education are the
key points for providing safe anesthesia for children, not all
hospitals will fulfill the requirements for safe practice. The
discussion about which place (specialist pediatric surgical center
or district hospital) the children should be operated on is still
ongoing in most developed countries. 184 If there is little disagreement
with the concept that all neonatal admissions should
be dealt with in neonatal surgical centers, the controversy still
exists for infants and young children. The view that only
anesthesiologists who have a regular commitment to pediatric
anesthesia should anesthetize children is regularly challenged by
the anesthesiologists working in general district hospitals. 185,186

2104 PART 6 ■ Specific Considerations
TABLE 127-12. Classification of the 284 Anesthetic Human Factors Derived From the 668 Events Reported in Pediatric
Anesthesia Incidents at Birmingham Children’s Hospital (2002–2004) 184
Factor % Subtype %
Error of judgment
Failure to check
Technical failure of skill
Inexperience
Inattention/distraction
Communication
Poor preoperative preparation/assessment
Lack of care
Drug dosage slip
Teaching
Pressure to do case
Other
Multiple and miscellaneous other causes (4% 1994–1997 vs 3% 1998–2004) not shown.
**P < .01 1998–2004 vs 1994–1997 by Z test. Adapted from Bhananker et al. 26
43
17.6
9.2
7.7
5.6
5.6
3.5
2.5
1.8
1.4
1.1
1.1
Inadequate depth of anesthesia
Inadvisable anesthetic technique
Anesthetizing child with upper respiratory infection
Trachea extubated at wrong time
Other error of judgment
Equipment
Tracheal tube
Intravenous/arterial line
Other failures to check
Central venous access
Local block/epidural
Airway
13.4
9.2
8.5
7.7
4.2
8.5
5.6
2.8
0.7
5.3
2.1
1.8
One of the major arguments of the latter is the management of
emergency in children—after trauma or in a surgical or medical
emergency—when the sickest child will be looked after by an
inexperienced pediatric anesthesiologist. There are many answers
to this important question. One might be to have an efficient
medical transportation system such as the one existing in France.
The French SMURs (Service Mobile d’Urgence et de Reanimation)
are run by doctors and a trained doctor (anesthesiologist,
pediatrician, or intensivist) is in charge of the patient during
transportation. Transportation is the best answer to many
problems. For example, intussusception is a common emergency
during early infancy. In 1992, Stringer et al. in the United
Kingdom reported that although some deaths were caused by
delayed diagnosis and late referral to hospital, 60% were related
to mismanagement in hospital. 187 Of the patients who died in
hospital, only one was under the care of a specialist surgeon, and
he had undergone laparotomy at another district general hospital.
The same conclusions were endorsed by the American pediatric
community; Bratton 188 demonstrated that children who received
care for intussusception in a large children’s hospital had decreased
risk of operative care, shorter length of stay, and lower hospital
charges compared with children who received care in hospitals
with smaller pediatric caseloads. The authors concluded that
transfer to a center with a high pediatric volume should be
considered if the child has an intussusception that cannot be
radiographically reduced, if the patient is hemodynamically stable,
and the time needed for transport is acceptable to the involved
staff. This emphasizes the need for pediatric surgeons and
pediatric anesthesiologists to provide appropriate care but also the
need for other specialists in the field of radiology, intensive care,
physiotherapy, and nursing. 189 In other words, a real pediatric
environment is one of the keys to safe care of children. 190
CONCLUSION
During the last 20 years, anesthesia-related morbidity and
mortality have dramatically decreased. This might be explained
by progresses in equipment and monitoring and the introduction
of new techniques and new drugs in clinical practice. However, it
is clear that training and experience in pediatric anesthesia
together with a regular practice are the most important factors in
reducing complications and even deaths due to anesthesia in
children. An effort to reorganize the health care system is
mandatory in all developed countries to achieve this goal. The
recommendations proposed by the specialized societies should be
endorsed by the governments of each country. The next step
would be to make efforts to improve outcome of anesthesia as
defined by reducing the so-called minor events that might have
deleterious consequences for some children. Any qualityinsurance
program should focus on such efforts, provided that the
prerequisites of improving safety have been fulfilled.
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