Error Traps in Pediatric Adenotonsillectomy: Clinical Patterns, Cognitive Pitfalls, and Evidence-Informed Mitigation Strategies.

BACKGROUND
 A recent upper respiratory tract infection is linked to the development of peri-operative respiratory complications. In this study we wanted to evaluate the effect of salbutamol premedication on the incidence of peri-operative respiratory adverse events in children with a recent upper respiratory tract infection (PRAE).
 METHODS
 A randomized clinical trial study that was conducted at the Children Welfare Teaching Hospital for a period of six months. It included 90 children aged ≤ 16 years who underwent a surgical operation under general anesthesia with a laryngeal mask airway or a tracheal tube and were divided into three groups; (had a recent URTI and received preoperative salbutamol, those who had a recent URTI and didn’t receive preoperative salbutamol, and those with no URTI group). The preferred outcome was the difference in the rate of occurrence of PRAE between children who had received salbutamol and those who hadn’t.
 RESULTS
 Four children with no URTI (13.3%) developed peri-operative respiratory adverse events. The incidence of bronchospasm and severe cough was significantly higher in patients with URTI and who didn’t receive preoperative salbutamol than in those with URTI who received preoperative salbutamol.
 CONCLUSIONS
 Preoperative salbutamol doses 10 – 30 minutes before surgery have been demonstrated to reduce and treat peri-operative respiratory adverse events.

Recent upper respiratory tract infection (URI) is associated with increased incidence of perioperative complications in children undergoing open heart surgery. As a result, surgery is often postponed. However, the effect of recent URI on the incidence of perioperative complications in children undergoing therapeutic cardiac catheterisation is unknown. We investigated the perioperative outcomes of congenital heart disease (CHD) children with recent URI who underwent elective therapeutic catheterisation. We prospectively included children treated for CHD. Before surgery, parents or legal guardians were interviewed to complete a questionnaire on the child's demographics, history of asthma and passive smoking, and URI symptoms. Recorded perioperative respiratory adverse events (PRAEs) included laryngospasm, bronchospasm, breath holding, oxygen desaturation, and severe cough. Information on postoperative dysphoria, fever, copious sputum, and vomiting was obtained by telephone 24 h after surgery. Of 363 included children, 169 had recently (within 2 weeks) had a URI. The URI did not affect the incidence of laryngospasm, bronchospasm, breath holding, fever, or vomiting. The incidence of desaturation, severe cough, dysphoria, and copious sputum were significantly increased. Independent risk factors for PRAEs in children with a recent URI included age, passive smoking, and presence of rhinorrhoea or moist cough. The lengths of stay in the hospital and intensive care unit were not significantly different between groups. Although recent URI increased the incidence of PRAEs in children undergoing therapeutic cardiac catheterisation, most CHD patients with recent URI can undergo elective therapeutic cardiac catheterisation without serious adverse events or prolonged hospitalisation.

BackgroundThe novel coronavirus disease (COVID-19) suddenly broke out in China in December 2019. Pandemic-related behavioral changes can cause perioperative respiratory adverse events in children with congenital heart disease (CHD). Here, we compared the incidence of perioperative respiratory adverse events (PRAEs) in CHD children with and without upper respiratory infection (URI) undergoing the cardiac catheterization before and during the COVID-19 pandemic.MethodsThis prospective observational single-center study was based at a tertiary care center in Shanghai, China. A total of 359 children with CHD with and without recent URI were included between January 2019 and March 2021. The overall incidence of PRAEs (laryngospasm, bronchospasm, coughing, airway secretion, airway obstruction, and oxygen desaturation) in non-URI and URI children undergoing elective cardiac catheterization was compared before and during the COVID-19 pandemic. A logistic regression model was fitted to identify the potential risk factors associated with PRAEs.ResultsOf the 564 children enrolled, 359 completed the study and were finally analyzed. The incidence of URIs decreased substantially during the COVID-19 pandemic (14% vs. 41%, P < 0.001). Meanwhile, the overall PRAEs also significantly declined regardless of whether the child had a recent URI (22.3% vs. 42.3%, P = 0.001 for non-URI and 29.2% vs. 58.7%, P = 0.012 for URI, respectively). Post-operative agitation in children without URI occurred less frequently during the pandemic than before (2.3% vs. 16.2%, P = 0.001). Behaviors before the COVID-19 pandemic (odds ratio = 2.84, 95% confidence interval [CI] 1.76–4.58) and recent URI (odds ratio = 1.79, 95% CI 1.09–2.92) were associated with PRAEs.ConclusionsCOVID-19 pandemic-related behavioral changes were associated with a reduction in PRAEs in non-URI and URI children undergoing elective therapeutic cardiac catheterization.

Definition of Clinical Outcomes in Pediatric Anesthesia Research: It Is Like the Tower of Babel!

Recent upper respiratory tract infection (URI) is a risk factor for the occurrence of peri-operative respiratory adverse events (PRAE). This risk may be higher in children with congenital heart disease (CHD), particularly in those undergoing interventional cardiac catheterisation. It is therefore essential to adapt the anaesthetic strategy in these children to prevent from the occurrence of PRAE. To determine whether intranasal dexmedetomidine (DEX) premedication can reduce the incidence of PRAE in children with recent URI undergoing interventional cardiac catheterisation. Randomised controlled trial. Single-centre study based at a tertiary care centre in Shanghai, China. A total of 134 children with CHD aged 0 to 16 years with recent URI undergoing interventional cardiac catheterisation. Children were randomised to receive either intranasal DEX 1.5 μg kg (DEX group) or intranasal saline (Placebo group) 30 to 45 min before anaesthesia induction. The incidence of PRAE. Intranasal DEX significantly reduced the incidence of PRAE (P = 0.001), particularly oxygen desaturation (P = 0.012). Most PRAE were observed during the emergence phase. The incidence of PRAE was comparable among the three types of left-right shunt CHD children in both groups. In children aged less than 3 years, the incidence of PRAE was significantly lower in the DEX group (P = 0.003). In contrast, the incidence of PRAE was comparable between the two groups in children aged at least 3 years. No differences in the incidence of emergence agitation, fever and vomiting between the two groups were noted. Administration of intranasal DEX 1.5 μg kg 30 to 45 min before induction led to a reduction in the incidence of PRAE in children aged less than 3 years with recent URI undergoing interventional cardiac catheterisation. chictr.org.cn identifier: ChiCTR-RRC-17012519.

Backgroundandobjectives: Children are at greater risk of upper respiratory tract infection (URTI), which can pose a higher risk of perioperative respiratory adverse events (PRAEs), than adults. The purpose of this study was to validate the COLDS score as a pre-anesthetic risk assessment tool for predicting the possibility of PRAEs. Materials and methods: Children aged under 18 years and undergoing elective surgery were retrospectively included. Logistic regression analysis and the area under the receiver-operating characteristic (ROC) curve (AUC) were used to estimate the ability of the COLDS score to predict PRAEs. Propensity-matched comparison was evaluated using the cut-off value from the ROC curve. Results: Among the 6252 children, 158 children had a recent URTI and 34 cases of PRAEs were reported. Age, current symptoms, and COLDS score were found to be significant variables in predicting PRAEs. From the ROC curve, values of 0.652 (p = 0.007) for AUC and 12.5 for the cut-off value of the COLDS score were calculated. Propensity-matched comparison revealed that each and every component of COLDS contributed to the higher COLDS score group. In addition to higher COLDS score, younger age and current URTI symptoms were found to be significant risk factors for PRAEs. Conclusions: This study validated the predictive power of COLDS score as a risk assessment tool for children with URTI undergoing elective surgery under general anesthesia.

Unequal Rates of Serious Perioperative Respiratory Adverse Events Between Black and White Children

PurposeIn pediatric patients, the most common reason for delaying surgical intervention is an upper respiratory tract infection (URI). To date, there has been no consensus regarding the optimal timeframe for deferring surgery in children with URI. We conducted this study to evaluate whether a URI symptom-free period and other risk factors affect the incidence of perioperative respiratory adverse events (RAEs).Patients and MethodsThe study population included 267 pediatric patients (aged 0 to 13 years) with a recent URI episode who underwent surgery under general anesthesia. Following a retrospective review of medical records, several risk factors including a URI symptom-free period for intra- and postoperative RAEs were analyzed using univariate and multivariate logistic regression analyses.ResultsRAEs occurred in 23 of 267 patients (8.6%). Univariate analysis revealed that abnormal preoperative chest images (odds ratio [OR], 7.48; 95% confidence interval [CI], 2.46–22.68, p < 0.001) and emergency operations (OR, 2.84; 95% CI, 1.03–7.81, p = 0.04) were associated with RAEs. Four variables (abnormal preoperative chest images, emergency operations, age under 1 year and symptom-free period of 7–13 days) with a significance of <0.20 in the univariate logistic regression analysis were selected as candidate risk factors for the multivariate model. Among the four variables, abnormalities in preoperative chest images (OR, 7.60; 95% CI, 2.28–25.3, p = 0.001) and a symptom-free period of 7–13 days (OR, 0.13; 95% CI, 0.02–0.88, p = 0.04) were independently associated with RAEs in multivariate logistic regression analysis.ConclusionFor pediatric patients who require surgery and have a recent history of URI, procedures should be performed after a URI symptom-free period of at least 1–2 weeks. Confirming the absence of abnormalities in preoperative chest images can reduce the incidence of perioperative RAEs.

Background and aimsPediatric patients undergoing surgeries under general anesthesia (GA) who have a recent upper respiratory tract infection (URTI) pose a unique challenge for the anesthesiologists. We aimed to utilize the COLDS score as a pre-anesthetic risk assessment tool to predict the likelihood of perioperative respiratory adverse events (PRAEs) in children with URTI.Methods and materialsAfter ethical approval, we prospectively collected data over six months from children undergoing various ear, nose, and throat (ENT) surgeries under GA. Children above one year undergoing elective ENT surgeries were included. Children less than one year, non-ENT surgical pediatric patients, and those undergoing emergency surgeries were excluded.ResultsA total of 270 patients were included in the analysis, among whom 25 (9.3%) experienced postoperative events. The COLDS score was able to effectively distinguish between patients who did and did not experience postoperative complications. The receiver operating characteristic (ROC) curve (AUC) of 0.92 (95% CI: 0.86-0.99) suggests a strong discriminatory ability of the score. The specificity of the model was high at 97.96% (95% CI: 95.9-99.6), suggesting a strong ability to correctly identify patients without events. The sensitivity was lower at 40.0% (95% CI: 20.7-60.0), i.e., only 40% of patients who experienced complications were detected by the score.ConclusionsCOLDS score can help in distinguishing patients who will and will not have PRAEs. But as the sensitivity is moderate, we recommend using the COLDS score along with a detailed clinical assessment based on the type of surgery planned.

The first-line treatment of obstructive sleep apnea syndrome in children is adenotonsillectomy, but this may result in perioperative respiratory adverse events (PRAEs). The primary aim of this study is to examine whether the McGill oximetry score (MOS) and other polysomnography parameters can predict major PRAEs following adenotonsillectomy. We secondarily evaluated the MOS interrater reliability and correlation with other polysomnography parameters. This retrospective study included all children aged 0-18 years who underwent preoperative polysomnography between June 2010 and January 2016 prior to adenotonsillectomy at a tertiary pediatric institution. Oximetries from polysomnograms were assigned an MOS. Univariable and multivariable models for prediction of major PRAEs were constructed. MOS was correlated with polysomnography parameters and interrater reliability was evaluated. This study included 106 children; 15 had a major PRAE. A multivariable prediction model that combined MOS and age showed evidence for the ability to predict major PRAEs with an area under the receiver operating characteristic curve of 0.68 (95% confidence interval: 0.52, 0.84), whereby increased MOS and younger age were associated with PRAEs, but apnea-hypopnea index was not. MOS had excellent interrater reliability (κ = 0.95) and was highly correlated with oxygen saturation nadir and cumulative time percentage with oxygen saturation less than 90%. A prediction model including MOS and age may predict PRAEs following adenotonsillectomy. This suggests that nocturnal oximetry provides the most essential information of polysomnography measures to direct postoperative monitoring following adenotonsillectomy. Xiao L, Barrowman N, Momoli F, etal. Polysomnography parameters as predictors of respiratory adverse events following adenotonsillectomy in children. J Clin Sleep Med. 2021;17(11):2215-2223.

There is ongoing debate regarding the optimal timing for tracheal extubation in children at increased risk of perioperative respiratory adverse events, particularly following adenotonsillectomy. To assess the occurrence of perioperative respiratory adverse events in children undergoing elective adenotonsillectomy extubated under deep anaesthesia or when fully awake. Prospective, randomised controlled trial. Tertiary paediatric hospital. One hundred children (<16 years), with at least one risk factor for perioperative respiratory adverse events (current or recent upper respiratory tract infection in the past 2 weeks, eczema, wheezing in the past 12 months, dry nocturnal cough, wheezing on exercise, family history of asthma, eczema or hay fever as well as passive smoking). Deep or awake extubation. The occurrence of perioperative respiratory adverse events (laryngospasm, bronchospasm, persistent coughing, airway obstruction, desaturation <95%). There were no differences between the two groups with regard to age, medical and surgical parameters. The overall incidence of complications did not differ between the two groups; tracheal extubation in fully awake children was associated with a greater incidence of persistent coughing (60 vs. 35%, P = 0.028), whereas the incidence of airway obstruction relieved by simple airway manoeuvres in children extubated while deeply anaesthetised was greater (26 vs. 8%, P = 0.03). There was no difference in the incidence of oxygen desaturation lasting more than 10 s. There was no difference in the overall incidence of perioperative respiratory adverse events. Both extubation techniques may be used in high-risk children undergoing adenotonsillectomy provided that the child is monitored closely in the postoperative period. Australian New Zealand Clinical Trials Registry: ACTRN12609000387224.

The use of topical lidocaine, applied to the airways with various administration techniques, is common practice in pediatric anesthesia in many institutions. However, it remains unclear whether these practices achieve their intended goal of reducing the risk of perioperative respiratory adverse events (PRAE) in children undergoing elective endotracheal intubation without neuromuscular blockade (NMB). The relative frequency of PRAE (laryngospasm, coughing, desaturation <95%) associated with no use of topical airway lidocaine (TAL), with TAL sprayed directly onto the vocal cords, and TAL administered blindly into the pharynx was assessed. This prospective audit involved 1000 patients undergoing general anesthesia with elective endotracheal intubation without NMB. Patients with suspected difficult airways or undergoing airway surgery were excluded. The use of TAL and the mode of administration were recorded. Respiratory adverse events were recorded in the perioperative period. Two hundred and fifty-four patients had the vocal cords sprayed under direct vision, 236 had lidocaine blindly dripped into the pharynx, and 510 received no TAL. The mean age and known risk factors for PRAE (asthma, recent upper respiratory tract infection (≤2 weeks), passive smoking, hayfever, past or present eczema, nocturnal dry cough) were similar among the groups. The proportion of patients with desaturation (<95%) between induction of anesthesia and discharge from the recovery room was higher in the two groups who received TAL (data combined for all patients receiving lidocaine regardless of administration method, P = 0.01) compared to those who received no TAL. No difference in the rates of laryngospasm (P = 0.13) or cough (P = 0.07) was observed among the groups. There was no difference in the rates of PRAE between the groups given TAL directly onto the vocal cords and in those whom received TAL blindly. The incidence of desaturation was higher in patients receiving TAL compared with children who did not. This association should perhaps be considered when contemplating the use of this technique.

Anesthesia for the child who presents for surgery with an upper respiratory infection (URI) presents a challenge for the anesthesiologist. The Current prospective study was designed to determine the incidence of and risk factors for adverse respiratory events in children with URTs undergoing elective surgical procedures. The study population included 1,078 children aged 1 month to 18 yr who presented for an elective surgical procedure. Parents were given a short questionnaire detailing their child's demographics, medical history, and presence of any symptoms of a URT. Data regarding the incidence and severity of perioperative respiratory events were collected prospectively. Adverse respiratory events (any episode of laryngospasm, bronchospasm, breath holding > 15 s, oxygen saturation < 90%, or severe cough) were recorded. In addition, parents were contacted 1 and 7 days after surgery to determine the child's postoperative course. There were no differences between children with active URIs, recent URIs (within 4 weeks), and asymptomatic children with respect to the incidences of laryngospasm and bronchospasm. However, children with active and recent URIs had significantly more episodes of breath holding, major desaturation (oxygen saturation < 90%) events, and a greater incidence of overall adverse respiratory events than children with no URIs. Independent risk factors for adverse respiratory events in children with active URIs included use of an endotracheal tube (< 5 yr of age), history of prematurity, history of reactive airway disease, paternal smoking, surgery involving the airway, the presence of copious secretions, and nasal congestion. Although children with URIs had a greater incidence of adverse respiratory events, none were associated with any long-term adverse sequelae. The current study identified several risk factors for perioperative adverse respiratory events in children with lulls. Although children with acute and recent URIs are at greater risk for respiratory complications, these results suggest that most of these children can undergo elective procedures without significant increase in adverse anesthetic outcomes.

Objective: The primary objective is to determine the incidence of perioperative respiratory adverse events (PRAEs) in pediatric patients with upper respiratory tract infections (URIs) undergoing general anesthesia (GA); the secondary objective is to identify associated risk factors, including the COLDS score. Materials and Methods: This retrospective cohort study included pediatric patients aged 0–18 years with URIs who underwent surgery under GA at the Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, between January 1, 2018, and December 31, 2022. Results: A total of 229 pediatric patients were analyzed, with a PRAE incidence of 3.9%. In univariable logistic regression analysis, the American Society of Anesthesiologists (ASA) classification III, severe URI, underlying respiratory disease, endotracheal tube use, emergency surgery, and minor airway surgery (compared with other surgery types) were identified as factors associated with PRAEs. In multivariable analysis, only ASA classification III compared with ASA classification II (adjusted odds ratio [OR] 83.33; 95% CI, 7.10 to 1363.56; p &lt; 0.001) and minor airway surgery compared with other surgery types (adjusted OR 18.54; 95% CI, 1.97 to 237.98; p = 0.009) remained significantly associated with PRAEs. Conclusion: The incidence of PRAEs in pediatric patients with URIs undergoing GA was 3.9%. ASA classification III and minor airway surgery were associated with PRAEs. Careful preoperative assessment and targeted prevention strategies are recommended for pediatric patients with URIs to reduce PRAEs.

Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study