Pediatric Ambulatory Anesthesia Research Articles

Evaluation of risk prediction model for perioperative respiratory adverse events in pediatric anesthesia

Background: Perioperative respiratory adverse events are among the most common critical incidents in pediatric anesthesia. Three risk prediction models have been developed to predict occurrence of such adverse events in children. However, these tools were only internally validated, limiting generalization. The Perioperative Respiratory Adverse Events in Pediatric Ambulatory Anesthesia risk prediction tool developed by Subramanyam et al. consists of five predictors: age ≤ 3 years, ASA physical status II and III, morbid obesity, preexisting pulmonary disorder, and surgery. Aims and Methods: We aimed to evaluate the suitability of Subramanyam’s model in predicting the occurrence of perioperative respiratory adverse events in a more general tertiary care pediatric population, including anesthesia for both outpatient and inpatient procedures. Therefore we validated this scoring system in a tertiary care cohort of 204 children included in the APRICOT study at our hospital through retrospective analysis of this data. Secondarily, we aimed to study the incidence of perioperative respiratory adverse events in our hospital. Results: Overall incidence of perioperative respiratory adverse events in our sample was 19,6%. Applying Subramanyam’s prediction model to our cohort, we found no patients categorized as low risk, 76 patients as intermediate risk and 128 patients as high risk. Discriminatory ability of the risk scoring system was modest, with AUC of the simplified model 0,65 (95% CI 0,57-0,74) and AUC of the original logistic regression model 0,66 (95% CI 0,57-0,75). Calibration of the simplified model was rather poor, with Brier score 0,49. The original logistic regression model calibrated better, with Brier score 0,18. A subgroup analysis considering solely ambulant patients in Ghent-APRICOT yielded comparable results. Conclusions: We conclude that the overall performance of Subramanyam’s risk prediction tool in our cohort was moderate. Modest discrimination and calibration suggest that the risk score may not reliably predict perioperative respiratory adverse events in individual patients in our tertiary care pediatric population. Therefore the clinical relevance of the implementation of this scoring system in our tertiary hospital would be negligible, which leaves us with the lack of good scoring systems to predict perioperative respiratory adverse events in our population. In addition, we found the incidence of these adverse events in our hospital to be markedly higher as compared to the sample of Subramanyam.

Ambulatory Anesthesia, An Issue of Anesthesiology Clinics, Volume 37, Number 2

Ambulatory Anesthesia, An Issue of Anesthesiology Clinics, Volume 37, Number 2

Perioperative Respiratory Adverse Events in Pediatric Ambulatory Anesthesia: Development and Validation of a Risk Prediction Tool.

Perioperative respiratory adverse events (PRAEs) are the most common cause of serious adverse events in children receiving anesthesia. Our primary aim of this study was to develop and validate a risk prediction tool for the occurrence of PRAE from the onset of anesthesia induction until discharge from the postanesthesia care unit in children younger than 18 years undergoing elective ambulatory anesthesia for surgery and radiology. The incidence of PRAE was studied. We analyzed data from 19,059 patients from our department's quality improvement database. The predictor variables were age, sex, ASA physical status, morbid obesity, preexisting pulmonary disorder, preexisting neurologic disorder, and location of ambulatory anesthesia (surgery or radiology). Composite PRAE was defined as the presence of any 1 of the following events: intraoperative bronchospasm, intraoperative laryngospasm, postoperative apnea, postoperative laryngospasm, postoperative bronchospasm, or postoperative prolonged oxygen requirement. Development and validation of the risk prediction tool for PRAE were performed using a split sampling technique to split the database into 2 independent cohorts based on the year when the patient received ambulatory anesthesia for surgery and radiology using logistic regression. A risk score was developed based on the regression coefficients from the validation tool. The performance of the risk prediction tool was assessed by using tests of discrimination and calibration. The overall incidence of composite PRAE was 2.8%. The derivation cohort included 8904 patients, and the validation cohort included 10,155 patients. The risk of PRAE was 3.9% in the development cohort and 1.8% in the validation cohort. Age ≤ 3 years (versus >3 years), ASA physical status II or III (versus ASA physical status I), morbid obesity, preexisting pulmonary disorder, and surgery (versus radiology) significantly predicted the occurrence of PRAE in a multivariable logistic regression model. A risk score in the range of 0 to 3 was assigned to each significant variable in the logistic regression model, and final score for all risk factors ranged from 0 to 11. A cutoff score of 4 was derived from a receiver operating characteristic curve to determine the high-risk category. The model C-statistic and the corresponding SE for the derivation and validation cohort was 0.64 ± 0.01 and 0.63 ± 0.02, respectively. Sensitivity and SE of the risk prediction tool to identify children at risk for PRAE was 77.6 ± 0.02 in the derivation cohort and 76.2 ± 0.03 in the validation cohort. The risk tool developed and validated from our study cohort identified 5 risk factors: age ≤ 3 years (versus >3 years), ASA physical status II and III (versus ASA physical status I), morbid obesity, preexisting pulmonary disorder, and surgery (versus radiology) for PRAE. This tool can be used to provide an individual risk score for each patient to predict the risk of PRAE in the preoperative period.

Quality in Pediatric Ambulatory Anesthesia

Quality in Pediatric Ambulatory Anesthesia

French current practice for ambulatory anesthesia in children: a survey among the French‐speaking Pediatric Anesthesiologists Association (ADARPEF)

This survey aims to describe current practice in ambulatory care among pediatric anesthesiologists in France. Members of the French-speaking Pediatric Anesthesiologists Association (ADARPEF) were sent a questionnaire examining the proportion of pediatric ambulatory anesthesia practiced by each responder, the level of adherence to pediatric ambulatory Anesthesia guidelines, and responder consensus in decision making when faced with common case scenarios in pediatric ambulatory anesthesia. For the latter, consensus was defined as a > 80% opinion. One hundred and forty-five pediatric anesthesiologists replied (43%). Ambulatory anesthesia appears underused in France. Recent French pediatric ambulatory anesthesia guidelines are being applied. Postoperative pain is poorly managed. The choice of scheduling children for ambulatory anesthesia appears to be more heavily influenced by practitioners' subjective evaluation than evidence from the literature. A better commitment for ambulatory care must be found among anesthesiologists. Further studies are required to improve coherence, safety, and efficiency of children selection for ambulatory anesthesia.

Pediatric ambulatory anesthesia in 2006

In 2006, we have further defined the optimal types of pediatric patients and procedures for ambulatory management in major medical centers and free-standing surgery centers. This review presents a summary of our experience with ambulatory surgical patients at The Children’s Hospital of Philadelphia. Preoperative, intraoperative, and postoperative concerns are addressed. In addition, criteria for ambulatory management, on the basis of patient health status, are reviewed in detail.

Performance of a pediatric ambulatory anesthesia program – a developing country experience

The aim of this study was to evaluate the performance of a pediatric ambulatory anesthesia program in a tertiary care teaching hospital in a developing country. Data on all pediatric patients (<16 years of age) scheduled to have elective day-care surgery during a 1 year period from January 1999 to December 1999 were collected retrospectively. An audit form was used to determine the specialty of the procedures, anesthesia techniques, postoperative analgesia, perioperative complications, unplanned admissions and outcomes with respect to morbidity and mortality. A total of 763 pediatric ambulatory surgical procedures were performed during the year of 1999. The procedures included general surgery, ENT, orthopedic and plastic surgery. The most common procedure was inguinal hernia repair followed by umbilical hernia repair, adenotonsillectomy and circumcision and 96% of the patients had general anesthesia. There were only three unplanned admissions (0.4%); one for a surgical reason and two for anesthetic reasons. There was no serious morbidity or mortality in any patient. Performance of pediatric day-care anesthesia has been good in our day-care unit and we have a successful ambulatory surgery program, despite the limitations of a developing country.

A Practice of Anesthesia for Infants and Children, 3rd Edition.

A Practice of Anesthesia for Infants and Children, 3rd Edition.

Pain management for pediatric ambulatory anesthesia

New developments in analgesic drugs and techniques are being applied to the pediatric population. Appropriate pain management for ambulatory surgery patients helps to facilitate early discharge and minimize postoperative morbidity. A variety of opioid-related drugs, as well as novel delivery routes for opioids, have been reported in the pediatric population. New pharmacokinetic information for acetaminophen has resulted in revised dosage recommendations; applications of the nonsteroidal antiinflammatory agents are also discussed. Furthermore, regional anesthesia and adjuncts are useful in the pediatric ambulatory surgery patient. Recent data on techniques for pain management after pediatric ambulatory surgery will help the anesthetist develop a comprehensive plan for the postoperative period.

Unanticipated Hospital Admissions, Postdischarge Morbidities and Emergency Room Visits Following Pediatric Ambulatory Anesthesia

Unanticipated Hospital Admissions, Postdischarge Morbidities and Emergency Room Visits Following Pediatric Ambulatory Anesthesia