Anesthetic Complications and Outcomes in Childrencsa.societyhq.com/meetings/2016winter/guide/... ·...

Anesthetic Complications and Outcomes in Children

2016 Winter Anesthesia Conference

Nancy L. Glass, MD, MBA, FAAPProfessor of Anesthesiology and Pediatrics,

Baylor College of Medicine and Texas Children’s Hospital, Houston TX

• None• Proud of SPA’s contributions to patient

safety

Disclosures

Learning ObjectivesAt the end of this presentation, participants will be able to:

• Describe historical & current efforts to measure perioperative complications in kids

• State common major complications, with their associated risks

• Specify changes to your own practice to prevent these complications

At the end of this presentation, participants will be able to:

• Describe historical & current efforts to measure perioperative complications in kids

• State common major complications, with their associated risks

• Specify changes to your own practice to prevent these complications

“John”• 4 yo for palatoplasty for velopharyngeal

insufficiency—to improve his speech• Mild motor and speech delay• Otherwise “healthy” but not a great eater

Show of Hands….

• How many of you have participated in the care of a child having an UNEXPECTED major complication of anesthesia?

What do we know?• Children are at a higher risk of cardiac arrest

during surgery and anesthesia than adults– Age, immaturity, comorbid conditions

Beecher & Todd, 1954 < 10y 14/10,000

Rackow, 1961 Infants < 1 y 16/10,000Children 1-12 y 6/10,000Adults 3.9/10,000

What do we know?

• Pediatric Anesthetic Mortality• POCA—perioperative cardiac arrests• Wake Up Safe—operative anesthesia• PRAN—regional anesthesia• PSRC—sedation• Pediatric Anesthetic Neurotoxicity

Pediatric Anesthetic Mortality

• Overall Mortality 0.4-1.6 / 10,000

• Higher rate for infants and cardiac surgery

From Gregory’s Pediatric Anesthesia, 5th ed, p.1153

How do we learn from RARE EVENTS, and use those lessons to change our

practices?

Prevention of RARE EVENTS requires a Systems Approach

POCA Registry• Anonymous, voluntary reporting from 80

institutions, denominator (# cases) unknown• POCA 1—1994-1997

– 289 CA, 150 related to anesthesia– 55 (37%) from medications: Halothane depression

(46%) + other meds (20%)– 55% in children < 1 y– 33% arrests in healthy ASA 1-2 (64% from meds)

Morray J et al, Anesthesiology 93: 6-14, 2000.

POCA Registry

• POCA 2—1998-2004 – 397 cardiac arrests – 49% anesthesia-related (193 cases)– 23% failure to wean from CPB– 17% uncontrolled surgical bleeding

Bhananker SM et al, Anesth Analg 2007;105:344-50.

POCA Registry 2: 1998-2004

• 75% ASA 3-5; fewer in the < 1 y group (38%)• Medication-related 18% More Sevo, less halothane• CV related 41%--Blood loss, inadequate replacement;

inadequate access; CVP complications• Respiratory 27%--Laryngospasm most common, all

recovered• Mortality 28%, ASA class and emergency status were

predictiveBhananker SM et al, Anesth Analg 2007;105:344-50.

Anesthesia-related CA in Children with CHD, 1994-2005

• Compared CA outcomes in kids with underlying heart disease to those without

• 373 arrests, 127 underlying heart defects• 70% < 2 yrs of age• Mortality 33% with CHD, 23% without (p = 0.048)• 26% CA occurred in cardiac O.R.s• 17% CA occurred in cath lab• 54% CA occurred in main O.R.s

Ramamoorthy C, Anesth Analg 2010; 110: 1376-82.

• Largest single group: single ventricle patients– Unrepaired 59%– Palliated 26%

• Highest mortality– Aortic stenosis 62%– Cardiomyopathy 50%

• Fundoplication with GT• EGD• Colostomy • ENT, including trach• Line placement

Anesthesia-related CA in Children with CHD, 1994-2005

Ramamoorthy C, Anesth Analg 2010; 110: 1376-82.

Cardiac Arrest in Children with CHDTCH SYSTEMS SOLUTIONS

• Cardiac anes screens kids with CHD• Cardiac anes consult process• Cardiac anes staff some of these cases in Main OR• Vigorous efforts to educate/prepare generalists

to care for kids with CHD• Medico-legal issues?

POCA Registry: Limitations • Chest compressions

required—didn’t pick up “near-miss” situations

• No MH• No Latex allergies• No denominator• Some ascertainment biases• UNDER-REPORTING

AHA “Get with the Guidelines” Registry

• AHA QI project, ~ 1500 hospitals, > 3 m CA• ~20% Peds CA occur in PACU• 27 cases, 30% < 1 yr, 70% < 5 yrs• 12 (44%) respiratory• 6 (22%) cardiac • Remainder mixed

Christensen R et al, Ped Anes 2013

AHA “Get with the Guidelines” RegistryPACU Cardiac Arrests

• 63% survived to DC (higher than in-pt)• “Code team” called only 1/3 time—and NEVER

at night or on weekends.• Survival at night and on weekends was lower

Christensen R et al, Ped Anes 2013

Wake Up Safe• Prospective data: 1,026,128 ped anesthetics

registered to date (4/2014)• 1600 adverse events reported in 1051 patients• Four “alerts” issued by steering group

– Hyperkalemia-related cardiac arrests in infants receiving old blood

– Prevention of wrong side procedures– 2 Statements on medication errors

Wake Up Safe Results

050

100150200250300350400

With thanks to Don Tyler, MD, MBA, Exec Director of WUS, for sharing timely data

Wake Up Safe Results• Serious adverse events 1051 10.2/10,000• Deaths, Anes 1° cause: 0 0/10,000• Deaths, Anes 2° cause: 16 0.16/10,000• Wrong side/site: 9 0.09/10,000• Medication events: 212 2.07/10,000

With thanks to Don Tyler, MD, MBA, Exec Director of WUS, for sharing timely data

Hyperkalemic Cardiac Arrest• Four cases in one year (WUS)• Rapid administration of blood for surgical

bleeding: K+ > 8 mmol/L when RBC 23-28 days old, K+ > 6 when RBC > 5 days old

• Since 1970’s, 11 cases of CA related to transfusion, with 4 deaths; 8 cases reported to POCA registry between 1998-2004

Hyperkalemic Cardiac ArrestSYSTEMS SOLUTION

• Develop hospital protocol / Best Practices• Use blood less than 7 days old• If irradiated, use as soon as possible• Avoid hypovolemic low output state• Wash older blood units• Transfuse slowly if possible, through IV larger than a 22

ga—not thro central line

Wrong Site Surgery / Blocks• 5 cases reported to WUS in 2008

– 2 wrong side blocks– 3 wrong side surgeries

• Incidence of ~1:29,000 anes• No specific “time out” before blocks• Surgical time outs not universally

practiced– Inappropriate site marking,

failure to display images

Wrong Site Surgery / BlocksSYSTEMS SOLUTION

Medication Errors• Anesthesia providers are unique: prescribe, draw up,

dispense, administer• Incidence of serious drug errors is about 1:12,500,

roughly 20% of WUS errors– Wrong drug– Wrong dose– Wrong route– Omission of needed agent– Adverse rxns

Probably still under-reported !

Medication Errors: Solutions • Enhanced training, recognition—

insufficient by itself• Prefilled, labeled syringes• Optical labeling devices• Optical patient identifiers• Manufacturer assistance to avoid

similar labeling, packaging• Smart pumps

I am not recommending or advocating any specific vendor of safety/syringe labels

• Too slow, too clumsy, doesn’t fit our workflow

• Hard to adapt single system for 500 gm –500 lb patients

Current Technology

96 Deaths• Surgical 46

(38 bleeds)• Opioid toxicity 17• Anes complic 9

137 Periop Injuries• Bleeding 59• Impaired fcn 29• Anoxic event 20• Opioid toxicity 20

Just another T&A!Closed Claim Study 1984 - 2010

Subramanyam R, Intl Jrnl Ped Otorhinolaryngology 2013; 77:194-199

• CYP2D6 affects metabolism of codeine, hydrocodone, oxycodone, and tramadol

• Back to NSAIDs?• Who gets admitted, who

gets worked up for OSA?

Just another T&A!

Subramanyam R, Intl Jrnl Ped Otorhinolaryngology 2013; 77:194-199

• 111 cases of adverse events reported, 92 with adequate data for analysis (1990-2010, most after 2004)

• 86 (77%) died or had permanent neurologic injury

• 63 (57%) met criteria for OSA: obesity, +/- other comorbidities

Cote CJ, et al, Anesth Analg 2013

Cote CJ, et al, Anesth Analg 2013

Tonsillectomy Deaths

Avoidable deaths?• 10 children died/suffered neurologic injuries at

home within 24 hrs surgery• 3 died on the ward• 2 died in PACU

– 5 yo, first stage PACU, received morphine and midazolam, monitors removed, “sleeping” in dad’s arms

– 3 yo, 2nd stage PACU, no monitors, mom reclining on stretcher with child, thought he was “sleeping”

Cote CJ, et al, Anesth Analg 2013

Intra-Operative Disasters• What to do

• http://www.pedsanesthesia.org/

• Work of the SPA Quality and Safety Committee, headed by Dr. Genie Heitmiller. FREE for anyone to download / print / laminate / distribute

Pediatric Sedation Research Consortium

• Research arm of the multi-disciplinary Society for Pediatric Sedation

• 38 institutions have collected data on > 150,000 pediatric sedations since 2006

Pediatric Sedation Research Consortium

• >30,000 cases sedated by anesthesiologists, PICU or EC docs, 2004-2005, 26 institutions

• Mortality 0%, 1 cardiac arrest 2° hypoxemia• SaO2 < 90% for > 30 secs

– 157/10,000 or 1/64– 1/200 required rescue Cravero JP et al, Pediatrics 2006

Sept; 118(3): 1087-96

Pediatric Sedation Research Consortium

• 49,000 cases PROPOFOL sedations• CPR X 2 • Aspiration X 4• Central apnea / Airway obstruction

575/10,000 (5.75%), rescue required 1/70

Cravero JP, et al, Anesth Analg 2009 Mar;108(3): 795-804.

• 49,000 cases PROPOFOLsedations

• In well-developed systems, incidence of adverse outcomes is LOW

• Outcomes from non-anesproviders NOT different

• Training & ability to rescue are key

Adverse Event Incidence %

Stridor 50/10,000 0.5%

Laryngospasm 96/10,000 0.96%

Central apnea /obstruction

575/10,000 5.75%

Excessive secretions 341/10,000 3.41%

Vomiting 49/10,000 0.49%

Pediatric Sedation Research Consortium

Cravero JP, et al, Anesth Analg 2009 Mar;108(3): 795-804.

Are these results generalizable?

SYSTEMs THINKING is important!

• Protocols• Care standards• Education & training• Simulation

Pediatric Regional Anesthesia: Is it SAFE?

• French multi-institutional study of ~ 25,000 patients, no major sequelae. Methodologicflaws. Mostly caudal blocks.

• Pediatric Regional Anesthesia Network, a SPA-sponsored quality initiative for comprehensive, prospective data on every block since 4/1/2007

PRAN: Pediatric Regional Anesthesia Network

• Goal: look for incidence and risks of complications from regional blocks

• 18 institutions, not a random sampling• Identified adverse events: those that

changed therapy and those that didn’t• Looked for persistent sequelae

PRAN: Pediatric Regional Anesthesia Network

• 78,749 blocks on 68,236 patients*• Did not assess block effectiveness• Did not control for skill level of practitioner• Assuring post-discharge block follow-up is

difficult* Personal

communication April 2014

• Single shot blocks– 40% of ALL blocks were single shot caudals– Most UE blocks were supraclavicular

• Catheter techniques– 2,946 neuraxial catheters, 18% AE, 0.7%

complications; most AE related to catheter

PRAN: Pediatric Regional Anesthesia Network

Polaner DM et al, Anesth Analg 115(6):1353-64, 2012.

Neuraxial Catheters: 2,946• Wet tap 26 (0.9%), 4 requiring blood patch• Horner’s syndrome 4• Local inflammation or infection 32 (11%)

– No deep infection / abscess / sequelae• Respiratory depression 5 (0.2%)• Postoperative hypotension

Polaner DM et al, Anesth Analg 115(6):1353-64, 2012.

Summary• Regional anesthesia remarkably safe, most

complications occur at time of block placement• Use of ultrasound is increasing• Confirmation of catheter tip location is recommended• No LA toxicity seen• Wet tap and + blood aspirations are relatively common• Incremental dosing with LA is recommended

PRAN: Pediatric Regional Anesthesia Network

Polaner DM et al, Anesth Analg 115(6):1353-64, 2012.

Anesthetic Neurotoxicity

• What do we know about anesthetic neurotoxicity in young animals?

• Which drugs appear to be “bad?” Protective?

• Kids aren’t rats

What do we know?

• Exposure to anesthetic agents is associated with neurotoxicity in neonatal animals

• The clinical relevance of these findings for children is unknown / uncertain

• Studies suggest susceptibility early in life• The effects of unrelieved pain and other

physiologic stress are similar

Ongoing Studies• GAS: prospective study comparing infants

undergoing inguinal hernia repair under spinal vs. GA

• PANDA: following a group of children who had inguinal hernias prospectively with neurodevelopmental testing

• Danish registry: following 45,000 children who had surgery 1977-1990 before age 1 yr

Current Status• Children should have necessary surgery using

state-of-the-art techniques and monitoring • When appropriate and practical, consider

combining procedures

Another Story, 2012• Complicated and challenging case, VERY good

young staff, working alone.– Discussed extensively with cardiac team, other

consultants• Finally, it was over...• CRASH• Lots of SKILLED help arrived

Summary

• Reviewed outcomes for GA, regional blocks, sedation, and concern for anesthetic neurotoxicity

• Identified several ways to mitigate risks using a systems-based approach

• The overall risk of serious sequelae from pediatric anesthesia is VERY low.

VIGILANCE IS ALWAYS IN STYLE!