Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE).

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This review also includes:

Habre W, Disma N. A decade later, there are still major issues to be addressed in paediatric anaesthesia. Curr Opin Anaesthesiol. 2021;34(3):271-275. doi:10.1097/ACO.0000000000000990

de Graaff JC, Johansen MF, Hensgens M, Engelhardt T. Best practice & research clinical anesthesiology: Safety and quality in perioperative anesthesia care. Update on safety in pediatric anesthesia. Best Pract Res Clin Anaesthesiol. 2021;35(1):27-39. doi:10.1016/j.bpa.2020.12.007

This is an interesting collection of papers to consider together. The first is a large multicentre European study of anaesthetic interventions and perioperative outcomes of neonates. The two review articles share authors with the NECTARINE study and provide us with a strong analysis of associated research.

The NECTARINE study [1] follows the APRICOT study [2] and closely resembles it in its methods of recruitment & data collection, and so shares many of it is strengths and weaknesses. The study is the detailed prospective capture of neonatal and infant perioperative care and outcome data, including severe critical events and their treatment, in 31 European countries. It provides a snapshot overview of what are considered triggers for anaesthetic intervention in this population, however its voluntary nature and methods of recruitment may introduce a reporting bias as well as missing unusual cases and practices. Subgroup analysis of the APRICOT trial revealed differences in outcomes in different jurisdictions, perhaps due to differences in the differences in the types of centres recruiting and differences in training [3, 4]. Further investigation of this type with the NECTARINE data will be difficult due to the differences in patient numbers (NECTARINE n=5609 vs 31,127 in APRICOT).

The paper makes the point that a major finding is that > 60% of the interventions for hypoxaemia were triggered by a SpO2 of < 85%, regardless of age but does not investigate the contribution that cardiac (8.5% of surgical cases) or thoracic (1.1%) surgery has on this. Also of interest was that interventions for hypothermia occurred often well below 36^oC.

It is a useful paper in that it provides insight into what anaesthetists think are important parameters to defend, in the face of a lack of strong evidence. Its major issues are around the lack of differentiation between case types, anaesthesia experience or location.

The review paper by Habre and Disma [5] reflects what could be imagined to be the major frustrations incurred during the above study, namely the need to standardise clinical practice in paediatric anaesthesia, and the need for translational and clinical research in determining the thresholds for physiological parameters that should trigger interventions in neonatal and paediatric populations, and the implementation of common outcomes sets for each age-specific group by the Paediatric Perioperative Outcomes Group. The major interventions discussed are the increased use of dexmedetomidine and NIRs as well as video laryngoscopy and nasal cannula oxygenation during intubation of small children.

The paper by de Graaff et al. [6], does an excellent job of clarifying the data around safety in paediatric anaesthesia. It finds that anaesthesia in healthy children above 1 year of age has reached the level where the risk for fatal adverse events is less than 1 in 100,000 general anaesthesia procedures. As expected, mortality, morbidity and near miss rates are much higher in infants. The paper also provides evidence that years of experience of the anaesthetist (1% reduction in respiratory events and 2% reduction cardiovascular events for each year experience) as the annual number of days delivering anaesthesia to children (> annually 73 days) result in better outcomes. It also reinforces the commonly acknowledged themes of young age being a risk factor and respiratory events being the most common adverse outcomes.

Taken together these papers summarise and extend what has been an exciting decade in the advancement of quality and safety in paediatric, and especially neonatal anaesthesia. This started with the concerns raising questions around anaesthetic neurotoxicity and then progressing into the investigation into the standardisation of conduct and reporting, through the National Pediatric Anesthesia Safety Quality Improvement Program [7], APRICOT and NECTARINE trials and the formation of Paediatric Perioperative Outcomes Group [8].

References

1. Disma N, Veyckemans F, Virag K, et al. Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE). Br J Anaesth. 2021;126(6):1157-1172.
2. Disma N, Mondardini MC, Terrando N, Absalom AR, Bilotta F. A systematic review of methodology applied during preclinical anesthetic neurotoxicity studies: important issues and lessons relevant to the design of future clinical research. Paediatr Anaesth. 2016;26(1):6-36. doi:10.1111/pan.12786.
3. Engelhardt T, Ayansina D, Bell GT, et al. Incidence of severe critical events in paediatric anaesthesia in the United Kingdom: secondary analysis of the anaesthesia practice in children observational trial (APRICOT study). Anaesthesia. 2019;74(3):300-311. doi:10.1111/anae.14520
4. Hansen TG, Børke WB, Isohanni MH, Castellheim A; APRICOT Study Group of the European Society of Anaesthesiology Clinical Trial Network. Incidence of severe critical events in paediatric anaesthesia in Scandinavia: Secondary analysis of Anaesthesia PRactice In Children Observational Trial (APRICOT). Acta Anaesthesiol Scand. 2019;63(5):601-609. doi:10.1111/aas.13333
5. Habre W, Disma N. A decade later, there are still major issues to be addressed in paediatric anaesthesia. Curr Opin Anaesthesiol. 2021;34(3):271-275.
6. de Graaff JC, Johansen MF, Hensgens M, Engelhardt T. Best practice & research clinical anesthesiology: Safety and quality in perioperative anesthesia care. Update on safety in pediatric anesthesia. Best Pract Res Clin Anaesthesiol. 2021;35(1):27-39.
7. 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(1):112-121. doi:10.1213/ANE.0000000000000040
8. Muhly WT, Taylor E, Razavi C, et al. A systematic review of outcomes reported in pediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group. Paediatr Anaesth. 2020;10.1111/pan.13981. doi:10.1111/pan.13981

Reviewed by Donald Hannah