Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient

Abstract

There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.

Hot Topics in Safety for Pediatric Anesthesia

“…Perioperative respiratory adverse events are a cause of major morbidity and mortality, contributing to 30% of perioperative cardiac arrests, and can lead to increased length of stay, worsened outcomes, and higher hospital costs [ 11 , 12 ]. Risk factors include age less than 6 years, a recent (<4 weeks) or currently active upper respiratory tract infection (URI), pulmonary comorbidity (asthma, prematurity, cystic fibrosis, etc.…”

Perioperative respiratory adverse events in children undergoing triple endoscopy

“…Perioperative respiratory adverse events, in particular, are some of the most common critical events associated with anesthesia in children, comprising up to 75% of all critical perioperative events. 4 These events are associated with an increased length of hospital stay, increased hospital costs, and worsened patient outcomes. 4 The definition of a perioperative respiratory adverse event is variable in the literature, but commonly includes complications such as laryngospasm, bronchospasm, oxygen desaturation, airway obstruction, and respiratory failure after extubation.…”

“…4 These events are associated with an increased length of hospital stay, increased hospital costs, and worsened patient outcomes. 4 The definition of a perioperative respiratory adverse event is variable in the literature, but commonly includes complications such as laryngospasm, bronchospasm, oxygen desaturation, airway obstruction, and respiratory failure after extubation. 4 There are known patient-specific and procedure-specific factors associated with development of perioperative respiratory events in children.…”

The Importance of the Airway in Children Undergoing Surgery for Congenital Heart Disease

“…16,17 The most critical perioperative events in pediatric surgical patients have been found to be related to complications of the respiratory system. 18 It has been estimated that 75% of all perioperative adverse events involve the respiratory system, with 36% of these due to laryngospasm. 18,19 Children with CHD remain at risk for hypoxia and cardiovascular deterioration related to airway complications during planned and unplanned endotracheal extubations in the post-anesthesia and cardiac surgery convalescent periods.…”

“…18 It has been estimated that 75% of all perioperative adverse events involve the respiratory system, with 36% of these due to laryngospasm. 18,19 Children with CHD remain at risk for hypoxia and cardiovascular deterioration related to airway complications during planned and unplanned endotracheal extubations in the post-anesthesia and cardiac surgery convalescent periods. 20 In children undergoing anesthesia, respiratory causes are a major etiology of cardiac arrest in patients with and without heart disease, with the majority of these related to loss of airway patency.…”