Perioperative aspiration events in children: A report from the Wake Up Safe Collaborative.
complications
morbidity
multi-institutional
pediatric anesthesia
quality improvement
Journal
Paediatric anaesthesia
ISSN: 1460-9592
Titre abrégé: Paediatr Anaesth
Pays: France
ID NLM: 9206575
Informations de publication
Date de publication:
06 2020
06 2020
Historique:
received:
28
03
2019
revised:
02
04
2020
accepted:
15
04
2020
pubmed:
23
4
2020
medline:
29
7
2021
entrez:
23
4
2020
Statut:
ppublish
Résumé
Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death. We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration. The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments. Analysis included 2 440 810 anesthetics administered involving patients ≤18 years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA ≥ 4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%). Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.
Sections du résumé
BACKGROUND
Perioperative aspiration, while rare, is a serious complication of anesthetic care. Consequences of aspiration may include physical obstruction, wheezing, and pneumonia, resulting in mild to severe hypoxemia and even death.
AIM
We used a multi-institutional registry of pediatric patients to identify factors that influence the rate and resulting harm of perioperative pulmonary aspiration.
METHODS
The Wake Up Safe registry was queried for all severe adverse events reported from 29 institutions from 2010 to 2017. Aspiration events were identified through the "respiratory adverse event" data entry form or through free text search. Multivariable regression was used to predict aspiration events, and contributory factors were identified by reviewing free text case comments.
RESULTS
Analysis included 2 440 810 anesthetics administered involving patients ≤18 years of age. There were 135 pulmonary aspiration events, for an incidence of 0.006%. Within these 135 cases, 110 cases (82%) resulted in escalation of care and 51 (38%) resulted in patient harm, including 2 deaths (1.5%). In multivariable analysis, patients undergoing emergency surgery (OR 2.0 [1.2-3.5]) or with higher ASA status were more likely to experience aspiration (ASA 3 (OR 5.0 [2.6-9.1]); ASA ≥ 4 (OR 5.5 [3.8-16.8])). Noted causes of aspiration included gastrointestinal comorbid conditions (19%), postcoughing event or laryngospasm (14%), nil per os (NPO) violation (11%), blood or secretions in the airway following or during the procedure (6%), and oral premedication reaction (3%).
CONCLUSION
Although infrequent, death was reported as a consequence of perioperative aspiration in two patients. The frequency with which NPO violations were identified as a potential cause of aspiration highlights the struggles institutions face with adherence to NPO regulations, as these cases may be preventable. Furthermore, preventive measures may be needed to address other common causes of aspiration, such as gastrointestinal comorbid conditions.
Substances chimiques
Anesthetics
0
Types de publication
Journal Article
Multicenter Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
660-666Informations de copyright
© 2020 John Wiley & Sons Ltd.
Références
Tan Z, Lee SY. Pulmonary aspiration under GA: a 13-year audit in a tertiary pediatric unit. Paediatr Anaesth. 2016;26:547-552.
Ludlow CL. Laryngeal reflexes: physiology, technique, and clinical use. J Clin Neurophysiol. 2015;32:284-293.
Robinson M, Davidson A. Aspiration under anaesthesia: risk assessment and decision-making. Br J Anaesth. 2014;14:171-175.
Kelly CJ, Walker RW. Perioperative pulmonary aspiration is infrequent and low risk in pediatric anesthetic practice. Paediatr Anaesth. 2015;25:36-43.
Eisler L, Huang G, Lee KM, et al. Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data. Pediatr Anesth. 2018;28:218-225.
Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major adverse events and relationship to nil per os status in pediatric sedation/anesthesia outside the operating room: A report of the pediatric sedation research consortium. Anesthesiology. 2016;124:80-88.
Borland LM, Sereika SM, Woelfel SK, et al. Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome. J Clin Anesth. 1998;10:95-102.
Walker RW. Pulmonary aspiration in pediatric anesthetic practice in the UK: a prospective survey of specialist pediatric centers over a one-year period. Pediatr Anesth. 2013;23:702-711.
Warner MA, Warner ME, Warner DO, Warner LO, Warner EJ. Perioperative pulmonary aspiration in infants and children. Anesthesiology. 1999;90:66-71.
Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med. 2017;5:412-425.
Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: An updated report by the American Society of Anesthesiologists Task Force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology. 2017;126:376-393.
Green SM, Krauss BS, Mason KP. Reevaluating fasting for procedural sedation. JAMA Pediatr. 2018;172:622-623.
Bhatt M, Johnson DW, Taljaard M, et al. Association of preprocedural fasting with outcomes of emergency department sedation in children. JAMA Pediatr. 2018;172:678-685.
Beck CE, Rudolp D, Beck-Jakob K, et al. Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study. Pediatr Anesth. 2019;29(10):1040-1045.
Tjia I, Rampersad S, Varughese A, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119:122-136.
Kurth CD, Tyler D, Heitmiller E, Tosone SR, Martin L, Deshpande JK. National pediatric anesthesia safety quality improvement program in the United States. Anesth Analg. 2014;119:112-121.
Beazley B, Bulka CM, Landsman IS, Ehrenfeld JM. Demographic predictors of NPO violations in elective pediatric surgery. J Perianesth Nurs. 2016;31:36-40.
Mellin-Olsen J, Fasting S, Gisvold SE. Routine preoperative gastric emptying is seldom indicated. A study of 85,594 anaesthetics with special focus on aspiration pneumonia. Acta Anaesthesiol Scand. 1996;40:1184-1188.
deAguilar-Nascimento JE, Dock-Nascimento DB. Reducing preoperative fasting time: A trend based on evidence. World J Gastrointest Surg. 2010;27:57-60.
Alakkad H, Kruisselbrink R, Chin KJ, et al. Point-of-care ultrasound defines gastric content and changes the anesthetic management of elective surgical patients who have not followed fasting instructions: A prospective case series. Can J Anaesth. 2015;62:1188-1195.
Sharma S, Deo AS, Raman P. Effectiveness of standard fasting guidelines as assessed by gastric ultrasound examination: A clinical audit. Indian J Anaesth. 2018;62:747-752.
Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014;113:12-22.
Lipper B, Simon D, Cerrone F. Pulmonary aspiration during emergency endoscopy in patients with upper gastrointestinal hemorrhage. Crit Care Med. 1991;19:330-333.
Rudolph SJ, Landsverk BK, Freeman ML. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003;57:58-61.
Thomson A, Tye-Din J, Tonga S, et al. Aspiration in the context of upper gastrointestinal endoscopy. Can J Gastroenterol. 2007;21:223-225.
Hardy JF. Large volume gastroesophageal reflux: A rationale for risk reduction in the perioperative period. Can J Anaesth. 1988;35:162-173.
Ho AM, Ho AK, Mizubuti GB, Dion PW. Estimating the risk of a rare but plausible complication that has not occurred after n trials. Anesth Analg. 2018;127:1259-1263.