Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics.

Abstract

To the Editor: Excessive anesthesia-related morbidity and mortality in children has been explained in part by a lack of competency in pediatric anesthesiology [1]. As a result, precise guidelines defining competency by a minimum volume of pediatric anesthetics in this subspecialty have been established in the United Kingdom. We have studied the occurrence of complications in pediatric anesthesia and its relationship to pediatric practice in France through an anonymous retrospective postal survey. A survey packet consisting of a questionnaire requesting information about the anesthesiologists (age, sex, year of board certified), their practice (type of institution), their training, and the number of major complications experienced in 1993, a cover letter to explain the survey, and a prestamped envelope was sent to 5200 French anesthesiologists board-certified with a uniform standard in May of 1994. To characterize the anesthesiologists who did not respond to the first questionnaire, a second questionnaire requesting information regarding the anesthesiologists (age, sex, year of board certified) and the reasons for nonresponse was sent to 300 random nonrespondents. The responding anesthesiologists had a significantly lower age (mean +/- SD, 45 +/- 7 years versus 47 +/- 9 years) and had a significantly (P < 0.05) higher percentage of their practice in pediatric anesthesia (90% vs 63%) than the nonresponding anesthesiologists. The other characteristics were similar in both groups. Of the 173,700 pediatric anesthesics, respondents reported 351 complications: inadequate endotracheal intubation or ventilation (n = 161), anesthetic drug overdose (n = 105), cardiac arrest (n = 33), pulmonary aspiration (n = 27), complications due to regional anesthesia (n = 17; regional anesthesia was performed in 10% of the patients), and acute pulmonary edema (n = 8). Outcomes included death in five of the 33 cardiac arrest patients and serious neurologic sequelae due to hypoxia in one patient. A significantly (P < 0.05) higher incidence of complications was found in the groups that performed 1 to 100 (7.0 +/- 24.8 per 1000 anesthetics) and 100 to 200 pediatric anesthetics (2.8 +/- 10.1 per 1000 anesthetics) than in the group that administered more than 200 pediatric anesthetics/year (1.3 +/- 4.3 per 1000 anesthetics). Although interpretation of data reported herein must take into account clinical practice in France with Certified Registered Nurse Anesthetists and residents, they represent the first examination of the relationship between the number of complications and the volume of pediatric anesthetics administered per year. The potential biases in this study include self-report bias, which depends mostly on physician recall of events and nonresponse bias. In this study, self-report bias could manifest as a desire on the part of the anesthesiologists to appear cooperative. Indeed, the response rate in our study (904 of 4992 [18.4%], 208 undelivered) was closely similar to that of a recent retrospective postal study concerning anesthesia for infants requiring a pyloromyotomy (19%) [2]. However, the anonymous nature of the questionnaire makes it less likely that an individual intentionally reported untrue behaviors or perceptions. In addition, the data received could not be influenced in any way by fear of medical-legal consequences. In a report of complications, there are many confounding factors such as medical severity, operating room staffing, the ratio of nonspecialists, anesthetic drug used, and ratio of elective and emergency cases. However, the rate of cardiac arrests in our study (0.19 per 1000) was similar to a previous French report [3] and to a recent American report [4]. A recent French retrospective study based on a questionnaire showed an incidence of anaphylactic shock in France of 1/10,000 pediatric anesthetics [5], which was comparable to the incidence in our study (0.9/10,000). Despite the limitations of our study that we have outlined above, we recommend that a minimum case load of 200 pediatric anesthetics per year is necessary to reduce the incidence of complications and improve the level of safety in pediatric practice. Yves Auroy, MD Department of Anesthesiology; Hopital d'Instruction des Armees Begin; Vincennes, France Claude Ecoffey, MD Departments of Anesthesiology and Biostatistics; Hopital de Bicetre; Universite Paris-Sud; Kremlin Bicetre, France Antoine Messiah, MD Departments of Anesthesiology and Biostatistics; Hopital de Bicetre; Universite Paris-Sud; Kremlin Bicetre, France Bernard Rouvier, MD Department of Anesthesiology; Hopital d'Instruction des Armees Begin; Vincennes, France