Pediatrics

There are few studies of anesthesia-related risk in the pediatric population (see Chapter 60 ). Two themes emerge from these studies: Very young infants are at increased risk, and anesthesia-related risk is reduced in centers with specialized pediatric anesthesia facilities. In the report by Beecher and Todd,^[21] there was a "disproportionate number" of anesthesia-related deaths of children younger than 10 years.

Graff and colleagues^[149] from the Baltimore Anesthesia Study Committee reported 335 operative deaths in the pediatric age group. Of these, 58 were thought to be primarily or partially attributable to anesthesia. The percentage of operative deaths attributable to anesthesia was relatively constant among age groups at 16.6% to 21.7%. The estimated anesthesia-associated mortality rate was 3.3 deaths per 10,000 operations for those younger than 15 years, compared with 0.6 for those between 15 and 24 years old and 11.7 for those older than 64 years. More than one half of the patients were categorized as ASA physical status class I or II, suggesting that most deaths occurred in children with good anesthesia risk. Most deaths occurred during tonsillectomy, which probably reflects the fact that tonsillectomy is the most common operation in this age group. The investigators attempted to determine the phase of the operation that was associated with highest risk. Improper management of the anesthetic accounted for approximately one half of the cases. Respiratory complications (e.g., underventilation, aspiration of vomitus or blood) were apparent in 82% of the anesthesia-related deaths. The investigators suggested that female patients are at a better operative risk than male patients in all age groups.

Tiret and colleagues^[150] published a study of pediatric anesthesia risk in 1988. They prospectively studied major anesthesia-related complications in pediatric patients in 440 hospitals in France between 1978 and 1982. There were 27 major complications in 40,240 cases, which included 12 cardiac arrests and 1 death. The incidence of major complications and that of cardiac arrests were

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Cohen and colleagues^[151] studied 29,220 anesthesia procedures at the Winnipeg Children's Hospital. Data were collected from mid-1982 to 1987 and stored in a databank. Data on patients' coexisting medical conditions and postoperative follow-up were obtained within 72 hours. Complications included death, cardiac arrest, drug incident, airway obstruction, and minor complications such

TABLE 24-18 -- Summary of perioperative events by age group *

Event	<1 Month (n = 361)	1–12 Months (n = 2544)	1–5 Years (n = 13,484)	6–10 Years (n = 7184)	11+ Years (n = 5647)
Any intraoperative event	14.96	7.31	7.10	12.22	9.69
Any recovery-room event	16.61	7.23	12.20	14.88	15.23
Any postoperative event
Minor event †	13.57	10.30	20.32	31.49	32.44
Major event ‡	23.82	7.51	3.26	3.37	3.33
Any event §
Among patients seen	48.89	25.92	37.50	50.52	51.33
Among all patients	41.55	23.47	33.16	45.04	45.78
Adapted from Cohen MM, Cameron CB, Duncan PG: Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg 70:160, 1990.

*All figures are given as the percentage of events per total anesthetics.
†Includes nausea and vomiting, sore throat, muscle pain, headache, dental conditions, positional conditions, conditions involving extremities, eye conditions, croup, temperature, behavioral problem, thrombophlebitis, arterial line problem, awareness, and "other" problems.
‡Includes "other respiratory" conditions, cardiovascular disorders, nerve palsy, hepatic disorders, renal disorders, seizures, surgical complications, and death.
§Percentage of total anesthetics in which there was at least one event in the intraoperative, recovery-room, or later postoperative period.

In 1994, the Pediatric Perioperative Cardiac Arrest (POCA) Registry ^[152] was formed to determine the clinical factors and outcomes associated with cardiac arrest in anesthetized children. For institutions in the registry, standardized data from each cardiac arrest in an anesthetized child 18 years or younger are submitted. A total of 289 cardiac arrests occurred in the 63 institutions in the database during the first 4 years of the registry, of which 150 were judged to be related to anesthesia (1.4 per 10,000 anesthesia procedures), with a 26% mortality rate. Medication-related causes and cardiovascular causes of cardiac arrest were most common ( Fig. 24-7 ). Anesthesia-related cardiac arrest occurred most often in patients younger than 1 year of age and in patients with severe underlying disease. The goal of the registry is similar to that of the closed claims studies—to identify

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Figure 24-7 Causes of perioperative cardiac arrests in the pediatric population in the Pediatric Perioperative Cardiac Arrest Registry. Medication-related and cardiovascular (CV) causes of cardiac arrest were most common. (Adapted from Morray JP, Geiduschek JM, Ramamoorthy C, et al: Anesthesia-related cardiac arrest in children: Initial findings of the Pediatric Perioperative Cardiac Arrest [POCA] Registry. Anesthesiology 93:6, 2000.)