Chapter 127

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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
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