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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 <strong>127</strong> ■ 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 <strong>127</strong>–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
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Chapter 127

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