Elsevier

The Lancet

Volume 376, Issue 9743, 4–10 September 2010, Pages 773-783
The Lancet

Articles
Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study

https://doi.org/10.1016/S0140-6736(10)61193-2Get rights and content

Summary

Background

Perioperative respiratory adverse events in children are one of the major causes of morbidity and mortality during paediatric anaesthesia. We aimed to identify associations between family history, anaesthesia management, and occurrence of perioperative respiratory adverse events.

Methods

We prospectively included all children who had general anaesthesia for surgical or medical interventions, elective or urgent procedures at Princess Margaret Hospital for Children, Perth, Australia, from Feb 1, 2007, to Jan 31, 2008. On the day of surgery, anaesthetists in charge of paediatric patients completed an adapted version of the International Study Group for Asthma and Allergies in Childhood questionnaire. We collected data on family medical history of asthma, atopy, allergy, upper respiratory tract infection, and passive smoking. Anaesthesia management and all perioperative respiratory adverse events were recorded.

Findings

9297 questionnaires were available for analysis. A positive respiratory history (nocturnal dry cough, wheezing during exercise, wheezing more than three times in the past 12 months, or a history of present or past eczema) was associated with an increased risk for bronchospasm (relative risk [RR] 8·46, 95% CI 6·18–11·59; p<0·0001), laryngospasm (4·13, 3·37–5·08; p<0·0001), and perioperative cough, desaturation, or airway obstruction (3·05, 2·76–3·37; p<0·0001). Upper respiratory tract infection was associated with an increased risk for perioperative respiratory adverse events only when symptoms were present (RR 2·05, 95% CI 1·82–2·31; p<0·0001) or less than 2 weeks before the procedure (2·34, 2·07–2·66; p<0·0001), whereas symptoms of upper respiratory tract infection 2–4 weeks before the procedure significantly lowered the incidence of perioperative respiratory adverse events (0·66, 0·53–0·81; p<0·0001). A history of at least two family members having asthma, atopy, or smoking increased the risk for perioperative respiratory adverse events (all p<0·0001). Risk was lower with intravenous induction compared with inhalational induction (all p<0·0001), inhalational compared with intravenous maintenance of anaesthesia (all p<0·0001), airway management by a specialist paediatric anaesthetist compared with a registrar (all p<0·0001), and use of face mask compared with tracheal intubation (all p<0·0001).

Interpretation

Children at high risk for perioperative respiratory adverse events could be systematically identified at the preanaesthetic assessment and thus can benefit from a specifically targeted anaesthesia management.

Funding

Department of Anaesthesia, Princess Margaret Hospital for Children, Swiss Foundation for Grants in Biology and Medicine, and the Voluntary Academic Society Basel.

Introduction

Despite the development of guidelines for anaesthesia management, perioperative respiratory adverse events remain one of the major causes of morbidity and mortality during paediatric anaesthesia.1, 2, 3, 4 Many factors related to a child's medical history, anaesthesia management, and surgery contribute to their occurrence. Although previous studies have reported some risk factors for perioperative respiratory adverse events,2, 4, 5, 6, 7 whether children at high risk are being identified in clinical practice is uncertain.

Increased airway sensitivity, which can be associated with current asthma, recent upper respiratory tract infection, or passive smoking, probably increases the risk of perioperative respiratory adverse events.2, 5, 6, 7 The incidence of upper respiratory tract infection in children presenting for anaesthesia is high8 and the prevalence of asthma is increasing in the paediatric population,9 thus anaesthetists have to manage increasing numbers of children at high risk of perioperative respiratory adverse events in everyday clinical practice. However, most paediatric studies have focused on a specific population,10 a specific condition (eg, upper respiratory tract infection),5, 7 or the incidence of specific complications, particularly laryngospasm.5, 11

Accurate assessment of the risk of perioperative respiratory adverse events during the preanaesthetic assessment would enable anaesthetic management to be tailored to reduce the likelihood of those complications. A suitable risk assessment questionnaire that could be used in the preoperative setting would be useful, especially because perioperative consultations are changing from being medically-based to nurse-based.12

We aimed to identify any associations between family history, anaesthesia management, and occurrence of perioperative respiratory adverse events by assessing children preoperatively with an adapted version of the International Study Group for Asthma and Allergies in Childhood (ISAAC) questionnaire.13

Section snippets

Study design

We prospectively included all children who had general anaesthesia for surgical or medical interventions, elective or urgent procedures at Princess Margaret Hospital for Children, Perth, Australia, from Feb 1, 2007, to Jan 31, 2008. On the day of surgery, the anaesthetist in charge of the patient used the modified ISAAC questionnaire13 to record upper respiratory tract infection, including time of the infection (present, <2 weeks earlier, or 2–4 weeks earlier) and the symptoms involved (clear

Results

After the 12 months, 9297 questionnaires (from 10 496 children) were available for analysis. The mean age of the children was 6·21 years (SD 4·8). Table 1, Table 2 show demographic data and details of anaesthetic management.

1392 (15%) of 9297 children had perioperative respiratory adverse events: 193 (2%) had bronchospasm, 351 (4%) laryngospasm, 332 (4%) airway obstruction, 919 (10%) oxygen desaturation, 687 (7%) coughing, and 58 stridor (1%; table 3). Urgent procedures had a higher risk for

Discussion

Findings from this large prospective cohort study show that factors easily obtained at a preanaesthetic assessment, including respiratory symptoms, eczema, or a family history of asthma, rhinitis, eczema, or exposure to tobacco smoke, were associated with an increased risk for the occurrence of perioperative respiratory adverse events. Additionally, an upper respiratory tract infection was associated with an increased risk for perioperative respiratory adverse events only when the symptoms were

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