Small patients may have big problems: Complications of pediatric anesthesia

Abstract

Surveys of mortality associated with anesthesia performed 40 to 50 years ago, reported an increased risk of cardiac arrest and death in children. 1-3 The risk was considered especially great for those younger than 1 year of age, and was even higher for the newborn infant. The most common contributing factors in anesthesia-related death were respiratory: failure to ventilate, aspiration of stomach contents, and drug-induced ventilatory depression. Slightly less common factors involved the cardiovascular system: inadequate volume replacement, myocardial depression, and electrolyte disturbances. In one study that provided specific data, cardiac arrest due to anesthesia occurred during 1 in 719 anesthetics involving infants younger than 1 year, and during 1 in 2,326 anesthetics in children 1 to 12 years old? Of those children who had a cardiac arrest, only 16% made a complete recovery, 16% made a partial recovery, and 68% died. During the years since these studies, many advances have been made, both in our understanding of the physiology and pharmacology of pediatric anesthesia and in the techniques which we apply to anesthetize and monitor infants and children. It might therefore be anticipated that the rate of anesthesia-related cardiac arrest and mortality should have been progressively reduced. Comparisons, however, are difficult; although anesthesia care certainly should have improved, surgical procedures have also become more complex and are attempted in the more acutely ill patient. A retrospective study 4 of 12,712 anesthetics administered to children younger than 12 years of age during the years from 1969 until 1983 documented an incidence of anesthesia-related cardiac arrest of 1 in 2,128 cases. The principal cause in 5 of 6 cases was absolute overdose of halothane, and failure to ventilate was the cause of one arrest. Fully successful rescusitation was achieved in 50% of the patients who had a cardiac arrest. A multicenter prospective study of 40,240 pediatric patients conducted in France s during the years from 1978 to 1982 reports an incidence of anesthesia-related cardiac arrest of 1 in 5,000 for children 1 to 14 years of age and 1 in 526 for infants under 1 year of age. Only 1 child died, producing an overall anesthesia-related mortality rate of 1:40,000. Most of the patients who suffered cardiac arrest were successfully resuscitated. The incidence of major complications was increased in those with higher American Society of Anesthesiologists (ASA) risk classification, multiple coexisting diseases, and emergency surgery. Complications in infants occurred most commonly during maintenance of anesthesia and were usually the result of failure to maintain ventilation. Complications in children were equally divided between induction, maintenance, and recovery stages, and circulatory failure was associated as frequently as ventilatory failure. The anesthesia-related factors responsible for complications were airway mismanagement, intubation complications, aspiration, postoperative respiratory depression, halothane overdose, acute volume overload, and anaphylaxis af ter drugs (A1thesin, succinylchotine). A retrospective study of the years from 1983