Perioperative Cardiac Events (PCE)

NECTARINE

NEonate and Children audiT of Anaesthesia pRactice IN Europe

Morbidity and Mortality After Anesthesia in Early Life: Results of the NECTARINE Study

Introduction

Neonates and infants undergoing anesthesia face unique challenges due to their limited physiological reserve. The NECTARINE study, short for NEonate and Children audiT of Anaesthesia pRactice IN Europe, is a large-scale, European prospective observational study that sheds light on the risks and outcomes associated with anesthesia in early life.

Study Overview

Scope: Included 5,609 patients and 6,542 procedures across 165 centers in 31 European countries. Patients included were up to 60 weeks' postmenstrual age undergoing anesthesia for surgical or diagnostic procedures.
Objective: To identify triggers for medical interventions during anesthesia and evaluate associated morbidity and mortality rates.
Duration: Data collection spanned from March 2016 to January 2017.

Key Findings

High Incidence of Critical Events:
- 35.3% of procedures involved critical events requiring intervention.
- Hypotension (50%) and hypoxaemia (36%) were the most common complications.
- Parameter thresholds and related corrective interventions included:

1. SpO2, Pao2, or both (intervention to improve oxygenation)

2.End-tidal carbon dioxide (ETCO2), arterial/venous blood CO2 (intervention to improve alveolar ventilation), or both

3.Systolic or mean arterial blood pressure

4.Heart rate, ECG rhythm disturbances, or both, resulting in cardiovascular instability

5. Absolute values or relative changes in cerebral oxygenation when near-infrared spectroscopy (NIRS) was part of clinical monitoring

6. Blood glucose, plasma sodium (Na+), or both

7. Haemoglobin values (need transfusion of packed red cells)

8. Core body temperature values (correction for hypo/hyperthermia)

Morbidity and Mortality Rates:
- 30-day morbidity rate: 16.3%.
- Overall 90-day mortality: 3.2%.
Risk Factors:
- Preoperative intensive care support and longer surgical duration significantly increased risks.
Variability in Intervention Thresholds:
- Physiological thresholds for interventions, such as blood pressure and oxygenation levels, varied widely.
Implications for Practice:
- Findings highlight the need for standardized perioperative management guidelines.

Conclusion

The NECTARINE study emphasizes the vulnerability of neonates and infants during anesthesia and the importance of tailored interventions. These insights aim to refine clinical protocols and enhance the safety of anesthesia in this high-risk population.

Learn More

For a detailed look at the NECTARINE study, read the full publication here.

APRICOT

Anaesthesia PRactice In Children Observational Trial

Incidence of Severe Critical Events in Pediatric Anesthesia: Results of the APRICOT Study

Introduction

Children undergoing anesthesia face unique challenges due to their developing physiology and varying responses to anesthetic interventions. The APRICOT study (Incidence of Severe Critical Events in Pediatric Anesthesia: A Prospective Multicenter Observational Study) aimed to identify the frequency, nature, and outcomes of severe critical events in pediatric anesthesia across Europe.

Study Overview

Scope: Conducted across 261 hospitals in 33 European countries, involving 31,127 anesthesia procedures in 30,874 children.
Objective: To evaluate the incidence and risk factors associated with severe critical events during pediatric anesthesia.
Duration: Data were collected between April 1, 2014, and January 31, 2015.
Primary Endpoint: Occurrence of severe critical events requiring immediate intervention, including respiratory, cardiac, allergic, or neurological complications.

Key Findings

Incidence of Critical Events:
- Overall incidence of severe critical events: 5.2%
- Respiratory critical events: 3.1% (e.g., laryngospasm, bronchospasm)
- Cardiovascular instability: 1.9%
- 30-day in-hospital mortality rate: 10 in 10,000 cases
Risk Factors:
- Younger age and pre-existing medical conditions increased risk.
- Physical condition and medical history were significant predictors of complications.
- More experienced anesthesia providers were associated with a lower incidence of critical events.
Variability in Practice:
- Considerable differences in perioperative anesthesia management practices across Europe.
- Higher occurrence of respiratory complications compared to cardiovascular issues in infants and preschool-aged children.
Implications for Practice:
- The findings emphasize the need for standardized protocols and quality improvement initiatives to reduce variability and improve pediatric anesthesia safety.

Conclusion

The APRICOT study highlights the considerable incidence of severe critical events in pediatric anesthesia and underscores the need for specialized pediatric anesthetic training and protocol development to enhance patient outcomes.

Learn More

For a detailed analysis of the APRICOT study, read the full publication here.

Pediatric Perioperative Cardiac Arrest (POCA)

Anesthesia-Related Cardiac Arrest in Children: Update from the Pediatric Perioperative Cardiac Arrest (POCA) Registry

Introduction

The Pediatric Perioperative Cardiac Arrest (POCA) Registry was established in 1994 to track and analyze perioperative cardiac arrests in children. This update from the registry focuses on the period from 1998 to 2004, examining the changing causes and outcomes of cardiac arrests in pediatric anesthesia practice. Initial findings highlighted medication-related causes, but evolving anesthesia techniques and medications may have altered these trends.

Study Overview

Scope: Data were collected from nearly 80 institutions in North America that provide anesthesia for children.
Objective: To identify the primary causes of perioperative cardiac arrest and assess trends over time.
Duration: Data were collected from 1998 to 2004.
Methodology: A standardized data form was submitted for each perioperative cardiac arrest in children under 18 years of age.

Key Findings

Overall Trends:
- A total of 397 perioperative cardiac arrests were reported, with 193 (49%) being anesthesia-related.
- The incidence of medication-related arrests decreased significantly from 37% in 1994–1997 to 18% in 1998–2004.
- Cardiovascular causes were the most common, accounting for 41% of anesthesia-related arrests.
Major Causes of Cardiac Arrest:
- Cardiovascular causes (41%): Hypovolemia from blood loss and hyperkalemia from transfusion were the leading contributors.
- Respiratory causes (27%): Airway obstruction due to laryngospasm was the most common cause.
- Medication-related causes (18%): Decreased incidence attributed to reduced use of halothane in favor of sevoflurane.
- Equipment-related causes (5%): Central venous catheter complications were the most frequent equipment-related incidents.
Risk Factors:
- Higher ASA physical status (III–V) and emergency procedures were associated with increased mortality risk.
- The proportion of cardiac arrests among ASA I patients declined compared to earlier years, reflecting changing practice patterns.
Mortality Rates:
- Overall mortality after anesthesia-related cardiac arrest was 28%.
- Patients undergoing emergency surgery and those with preexisting comorbidities had the highest mortality rates.

Conclusion

The POCA Registry update reveals a shift in the causes of perioperative cardiac arrest in children, with fewer medication-related arrests and a greater emphasis on cardiovascular causes. Preventive strategies focusing on blood loss management, improved airway techniques, and careful monitoring during high-risk cases are essential to further reduce perioperative cardiac arrest rates.

Learn More

For a detailed analysis of the POCA Registry update, read the full publication here.

Perioperative Cardiac Events (PCE) Summary

The Perioperative Cardiac Events (PCE) category focuses on the identification, prevention, and management of critical cardiac events that occur in pediatric patients undergoing anesthesia. Children, especially those with congenital heart disease or other comorbidities, are at increased risk for perioperative complications such as cardiac arrest, hypotension, and arrhythmias. Research in this category aims to improve understanding of these events and develop evidence-based strategies to enhance perioperative safety.

Key Areas of Study:

Incidence and Risk Factors of Cardiac Arrest in Pediatric Anesthesia:
- The POCA Registry (2007) provides a comprehensive analysis of anesthesia-related cardiac arrests in children, highlighting key risk factors such as preexisting medical conditions, emergency procedures, and perioperative medication use. Findings emphasize the importance of proper perioperative monitoring and early recognition of critical signs to improve outcomes.
Critical Events During Pediatric Anesthesia Across Europe:
- The APRICOT Study (2017) examined the incidence of perioperative critical events in over 30,000 pediatric patients across Europe. The study identified common complications such as respiratory and cardiovascular instability and emphasized the need for standardized perioperative management protocols across institutions.
Morbidity and Mortality Associated with Anesthesia in Early Life:
- The NECTARINE Study (2022) analyzed perioperative outcomes in neonates and infants, revealing a high incidence of critical perioperative events, including hypotension and hypoxemia. The study underscored the need for specialized perioperative care and individualized management strategies for this vulnerable population.

Key Findings Across Studies:

Incidence Rates:
- Cardiac arrests occur in approximately 1 in 10,000 pediatric anesthetic cases, with higher rates in neonates and infants.
- Respiratory complications, including hypoxia and laryngospasm, are significant contributors to cardiac events.
Risk Factors:
- Emergency surgeries, ASA physical status III-V, and preexisting cardiac or respiratory conditions increase the likelihood of perioperative cardiac events.
- Delayed recognition and management of critical changes in hemodynamics can worsen outcomes.
Management Strategies:
- Early use of advanced airway techniques and cardiac monitoring improves outcomes.
- Multidisciplinary team collaboration and adherence to standardized protocols are essential in high-risk cases.

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