Critical incidents in paediatric anaesthesia: an audit of 10,000 anaesthetics in Singapore.
Tay CLM, Tan GM, NG SBA. Paediatric Anaesthesia 11:715-718, 2001.
Review: The authors of this report reviewed audit records for all anesthetics administered at KK Women's and Children's Hospital of Singapore during the period of May 1977 April 1999. Anesthetic care was provided by consultants (trained pediatric anesthesiologists), registrars and residents. Audit forms were completed for each case. Data collected included medical diseases, operative procedure, anesthetic technique including drugs administered, adverse events and outcome. An anesthetic critical incident was defined as "any incident which affected, or could have affected, the safety of the patient while under anesthetic care." Three deaths were reported; however, in each case death was attributed to the patient's medical condition, and anesthetic care was not considered to be contributory. There were 297 critical incidents reported in 278 patients. Infants experienced more incidents than older children, 8.6% vs. 2.1%. Respiratory problems accounted for 77% of all incidents, including 106 instances of laryngospasm and 101 instances of hypoxia, usually attributed to hypoventilation. Cardiovascular events were responsible for only 10.8% of incidents. Hemorrhage and hypotension were the most common cardiovascular problems. The majority (77%) of incidents occurred during elective surgery in healthy patients. Nevertheless, incidents were more likely when the ASA status > 3 (9.7% vs. 2.4%). The frequency was similar in elective and emergency cases, 2.7% and 2.9%, respectively. Combined general and regional techniques were common, yet only three incidents were reported in 3,993 regional techniques.
Comment: In an accompanying editorial, "Searching for the Holy Grail: measuring risk in paediatric anaesthesia," (Paediatric Anaesthesia 11:637-41) Johan H. van der Walt recounts the reports of the past four decades that document the tremendous advances in the safety of pediatric anesthesia practice. He considers this report to be important because it provides critical incident data with an accurate denominator and, in so doing, validates other recent reports concerning anesthesia risk. Comparing outcome data remains problematic due to inconsistencies in definitions and study designs, as well as more fundamental differences, such as anesthetic technique. For example, the authors of this article report that the majority of critical incidents involved laryngospasm during the maintenance period. In the discussion, however, they explain that these instances of laryngospasm occurred in the "immediate post-induction period" when patients were transferred from the parent's lap to the OR table. Clearly, they have identified a problem with their induction technique rather than with anesthetic maintenance. Dr. Van der Walt also poses other questions: What is the impact of specialized training upon risk and outcome? Does the volume of pediatric cases in an anesthesiologist's current practice affect outcome? Broad-based, multi-institutional data collection and analysis is necessary to effectively utilize outcomes research and establish useful standards of care.
Reviewed by: John T. Algren, MD
Vanderbilt Children's Hospital
Nashville, TN