Incidence of severe critical events in paediatric anaesthesia in Scandinavia: Secondary analysis of Anaesthesia PRactice In Children Observational Trial (APRICOT)

Abstract

Background: The Anaesthesia PRactice In Children Observational Trial (APRICOT) in 261 European hospitals revealed a 5.2% incidence of severe critical events in the perioperative period and wide variability in practice.

Methods: A sub-analysis of the Scandinavian data was undertaken to investigate differences from the rest of Europe in the incidence and nature of perioperative severe critical events and to attempt to identify areas for quality improvement.

Findings: In the Scandinavian cohorts of 1520 paediatric patients out of 31 127 patients, the overall incidence of perioperative severe critical events was lower than the rest of Europe (4.4% (95% CI [3.5-5.6]) vs 5.2% (95% CI [5.0-5.5]); RR 0.57), albeit the incidence varied across countries. There was a lower rate of bronchospasm (0.9%), stridor (1.1%) and cardiovascular instability (0.9%) than the rest of Europe. The proportion of bronchospasm events occurring at induction was 0.13% in Scandinavian cohort which was less than the rest of Europe (1.2%). The proportion of sicker patients where less experienced teams were managing the care was notably lower in Scandinavia than in the rest of Europe (14.4% vs 20.4% of the American Society of Anesthesiologists Physical Status Classification System Score (ASA-PS III and 8.3% vs 12.8% of the ASA-PS IV. Cardiovascular instability was lower in Scandinavia (0.92%) compared to Europe (1.9%). The incidence of drug errors was low in both the overall APRICOT (0.2%) and in Scandinavia (0.3%). There were no deaths.

Interpretation: This sub-analysis shows that current Scandinavia paediatric perioperative clinical practice compares favourably with the rest of Europe. The lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated paediatric anaesthesia providers managing the higher risk groups of patients in Scandinavia. Whether this cohort of anaesthetized children is truly representative of the entire Scandinavia countries is unknown. Areas for quality improvement include: standardisation of the definition of severe critical events, increased reporting, development of evidence-based protocols for the management of severe critical events, development and rational implementation of paediatric perioperative risk assessment scores, implementation of current best practice in the provision of competent paediatric anaesthesia service in Europe, development of specific training and ensuring maintenance skills in paediatric anaesthesia. Furthermore, based on data from the original Apricot paper children under the age of 3 years and ASA-PS III and IV patients should not be anaesthetised without direct supervision of a specialist in paediatric anaesthesia. Given the sample size of the Scandinavian cohort this conclusion cannot be investigated further.

Keywords: critical incident reporting; paediatric anaesthesia; quality improvement.