Taking stock of anaesthetic databases: enough data, time for action!

Abstract

For almost 60 years, the paediatric anaesthetic literature has witnessed multiple publications reviewing epidemiological data with regard to anaesthetic practice, including morbidity, mortality and risk. This edition of Anaesthesia contains the most recent of these, from Strøm et al. looking at the characteristics of those under two years of age undergoing anaesthesia [1]. However, after six decades where extraordinary improvements in information technology with regard to databases, processing data and the worldwide sharing of information have occurred, should we not be expecting more from such epidemiological surveys than just reaffirming what we already know, and should we be demanding more from our electronic information systems? Literature reviewThe earliest of these publications were retrospective studies that produced estimates of risk, but no assessment of risk factors [2][3][4][5]. The next 30 years saw the publication of five epidemiological studies [6-10], which Patterson and Waterhouse noted that, despite significant differences in the design of these studies, could be considered as a group because the risk profiles produced were nearly identical, (infants are at greater risk of complications, ASA physical status 3 or greater increases risk substantially) [11]. These studies are summarised in Table 1. Tiret et al. published the first prospective multicentre study quoting an anaesthetic mortality of 1:40,000, and with a significantly higher risk of incidents in infants than in children (1:250 vs. 1:2000, p < 0.001) which increased significantly with higher ASA physical status [6]. Tay et al. not only replicated these findings but also highlighted that respiratory events were the most frequent (77.4%), with laryngospasm accounting for 35.7% [7], while Murat et al. recorded an incidence of respiratory events of 53% [8]. Both acknowledged that their results were potentially affected by the underreporting that is endemic within a voluntary system. The first study investigating cardiac arrest in children (paediatric peri-operative cardiac arrest (POCA) registry) was published at the beginning of the millennium by Morray et al.; quoting a rate of 1.4:10,000 anaesthetics; over half of these occurred in infants and two-thirds occurred in ASA physical status 3 to 4 patients (accounting for 95% of deaths) [9]. Data for the following six years of the POCA registry were published in 2007 by Bhananker et al. and the main difference was a reduction in medication-related arrests, attributed predominantly to a reduction in halothane-induced cardiac arrest [10].Differences in the design of these studies and definitions of incidents might account for discrepancies between studies, and paradoxically, as practice becomes safer, the harder it becomes to demonstrate further improvements, particularly at any one institution [12]. Although beset with problems of under-reporting and how incidents were defined, the analysis of critical incidents can help to determine what improvements might be made. An analysis of critical incid...