Perioperative cardiac arrests were relatively higher in neonates, infants, the elderly and in males with severe underlying disease and under emergency surgery. All anaesthesia-related cardiac arrests were related to airway management and medication administration which is important for prevention strategies.

IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H 2 O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H 2 O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with SpO 2 Յ92% for >1 minute). RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, −2.3% [95% CI, −5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, −8.6% [95% CI, −11.1% to 6.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.

This systematic review of the Brazilian and worldwide literature aimed to evaluate the incidence and causes of perioperative and anesthesia-related mortality in pediatric patients. Studies were identified by searching EMBASE (1951-2011), PubMed (1966-2011), LILACS (1986-2011), and SciElo (1995-2011). Each paper was revised to identify the author(s), the data source, the time period, the number of patients, the time of death, and the perioperative and anesthesia-related mortality rates. Twenty trials were assessed. Studies from Brazil and developed countries worldwide documented similar total anesthesia-related mortality rates (<1 death per 10,000 anesthetics) and declines in anesthesia-related mortality rates in the past decade. Higher anesthesia-related mortality rates (2.4-3.3 per 10,000 anesthetics) were found in studies from developing countries over the same time period. Interestingly, pediatric perioperative mortality rates have increased over the past decade, and the rates are higher in Brazil (9.8 per 10,000 anesthetics) and other developing countries (10.7-15.9 per 10,000 anesthetics) compared with developed countries (0.41-6.8 per 10,000 anesthetics), with the exception of Australia (13.4 per 10,000 anesthetics). The major risk factors are being newborn or less than 1 year old, ASA III or worse physical status, and undergoing emergency surgery, general anesthesia, or cardiac surgery. The main causes of mortality were problems with airway management and cardiocirculatory events. Our systematic review of the literature shows that the pediatric anesthesia-related mortality rates in Brazil and in developed countries are similar, whereas the pediatric perioperative mortality rates are higher in Brazil compared with developed countries. Most cases of anesthesia-related mortality are associated with airway and cardiocirculatory events. The data regarding anesthesia-related and perioperative mortality rates may be useful in developing prevention strategies.

This systematic review of the Brazilian and worldwide literature aims to evaluate the incidence and causes of perioperative and anesthesia-related mortality. Studies were identified by searching the Medline and Scielo databases, followed by a manual search for relevant articles. Our review includes studies published between 1954 and 2007. Each publication was reviewed to identify author(s), study period, data source, perioperative mortality rates, and anesthesia-related mortality rates. Thirty-three trials were assessed. Brazilian and worldwide studies demonstrated a similar decline in anesthesia-related mortality rates, which amounted to fewer than 1 death per 10,000 anesthetics in the past two decades. Perioperative mortality rates also decreased during this period, with fewer than 20 deaths per 10,000 anesthetics in developed countries. Brazilian studies showed higher perioperative mortality rates, from 19 to 51 deaths per 10,000 anesthetics. The majority of perioperative deaths occurred in neonates, children under one year, elderly patients, males, patients of ASA III physical status or poorer, emergency surgeries, during general anesthesia, and cardiac surgery followed by thoracic, vascular, gastroenterologic, pediatric and orthopedic surgeries. The main causes of anesthesia-related mortality were problems with airway management and cardiocirculatory events related to anesthesia and drug administration. Our systematic review of the literature shows that perioperative mortality rates are higher in Brazil than in developed countries, while anesthesia-related mortality rates are similar in Brazil and in developed countries. Most cases of anesthesia-related mortality are associated with cardiocirculatory and airway events. These data may be useful in developing strategies to prevent anesthesia-related deaths.

Characteristics of included studies [ordered by study ID] Methods Design: randomized controlled trial Multicentre or single-centre: not reported Period: not reported Sample size: not reported. Generation of allocation: not reported. Allocation concealment: not reported. Blinding of assessment of treatment effect: not reported. Withdrawals: reported (less than 20%). Intention-to-treat analysis: not used. Follow up: until the fourth postoperative day Participants 172 participants. Sex (male/female): 59/113. Age (mean): 46.95 years. Setting: private hospital in Maracaibo, Venezuela. Inclusion criteria: patients undergoing abdominal surgery. Exclusion criteria: not reported Interventions Control group (no respiratory treatment): n = 44 patients. IPPB group (intermittent positive pressure breathing therapy for 15 minutes, four times daily): n = 45 patients). IS group (incentive spirometry four times daily): n = 42 patients). DBE group (deep breathing exercises under supervision for 15 min, four times daily): n = 41 patients) Outcomes Patients' body temperature, heart rate, forced vital capacity, forced expiratory volume in one second, forced expiratory flow from 25% to 75% of vital capacity, postoperative pulmonary complications, and length of stay Celli 1984 Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery (Review)

ResumoObjetivo: A agitação pós-operatória é um fenômeno clínico bem documentado em crianças, com incidência variando de 10 a 67%. Não existe explicação definitiva para a agitação no despertar. Várias causas têm sido discutidas na literatura, como rápido retorno à consciência em ambiente não familiar, presença de dor (ferida, dor de garganta, distensão vesical, etc.), estresse na indução, hipoxemia, obstrução da via aérea, ambiente barulhento, duração da anestesia, temperamento da criança, uso de medicação pré-anestésica e técnica anestésica empregada. O objetivo deste estudo é discutir as possíveis causas da agitação pós-operatória em crianças, subsidiando ações referentes à identificação e prevenção mais adequada. Fontes dos dados:Artigos originais e revisões, publicados no período de 1991 a 2007 e indexados no MEDLINE e PubMed, utilizando as seguintes palavras-chave: agitação no despertar, incidência, etiologia, diagnóstico, tratamento, criança, anestesia pediátrica.Síntese dos dados: É apresentada neste artigo uma revisão de possíveis desencadeadores de agitação, assim como uma proposta de escala para uniformização adequada do diagnóstico e medidas que implementam a prevenção e o tratamento. Conclusões:Nenhum fator pode, de maneira isolada, ser implicado como causador de agitação pós-operatória, devendo ser considerada como uma síndrome com componentes biológicos, farmacológicos, psicológicos e sociais, os quais o anestesiologista e o pediatra intensivista devem estar preparados para identificar, prevenir e intervir adequadamente quando necessário. J Pediatr (Rio J). 2008;84(2):107-113:Agitação no despertar, incidência, etiologia, tratamento, anestesia pediátrica, crianças. AbstractObjective: Postoperative agitation in children is a well-documented clinical phenomenon with incidence ranging from 10% to 67%. There is no definitive explanation for this agitation.Possible causes include rapid awakening in unfamiliar settings, pain (wounds, sore throat, bladder distension, etc.), stress during induction, hypoxemia, airway obstruction, noisy environment, anesthesia duration, child's personality, premedication and type of anesthesia. The purpose of this paper is to discuss the possible causes of postoperative agitation in children, providing a foundation for better methods of identifying and preventing this problem.Sources: MEDLINE and PubMed were searched using the following words: emergence, agitation, incidence, etiology, diagnosis, treatment, children, pediatric, anesthesia. Summary of the findings:This study includes a review of potential agitation trigger factors and a proposal for a standardized

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BackgroundLittle information is known about factors that influence perioperative and anesthesia-related cardiac arrest (CA) in older patients. This study evaluated the incidence, causes and outcome of intraoperative and anesthesia-related CA in older patients in a Brazilian teaching hospital between 1996 and 2010.MethodsDuring the study, older patients received 18,367 anesthetics. Data collected included patient characteristics, surgical procedures, American Society of Anesthesiologists (ASA) physical status, anesthesia type, medical specialty team and outcome. All CAs were categorized by cause into one of four groups: patient's disease/condition-related, surgery-related, totally anesthesia-related or partially anesthesia-related.ResultsAll intraoperative CAs and deaths rates are shown per 10,000 anesthetics. There were 100 CAs (54.44; 95% confidence intervals [CI]: 44.68–64.20) and 68 deaths (37.02; 95% CI: 27.56–46.48). The majority of CAs were patient's disease-/condition-related (43.5; 95% CI: 13.44–73.68). There were six anesthesia-related CAs (3.26; 95% CI: 0.65–5.87) - 1 totally and 5 partially anesthesia-related, and three deaths, all partially anesthesia-related (1.63; 95% CI: 0.0–3.47). ASA I-II physical status patients presented no anesthesia-related CA. Anesthesia-related CA, absent in the last five years of the study, was due to medication-/airway-related causes. ASA physical status was the most important predictor of CA (odds ratio: 14.52; 95% CI: 4.48–47.08; P<0.001) followed by emergency surgery (odds ratio: 8.07; 95% CI: 5.14–12.68; P<0.001).ConclusionsThe study identified high incidence of intraoperative CAs with high mortality in older patients. The large majority of CAs were caused by factors not anesthesia-related. Anesthesia-related CA and mortality rates were 3.26 and 1.63 per 10,000 anesthetics, with no anesthesia-related CA in the last five years of the study. Major predictors of intraoperative CAs were poorer ASA physical status and emergency surgery. All anesthesia-related CAs were medication-related or airway-related, which is important for prevention strategies.