Respiratory Complications in the Pediatric Postanesthesia Care Unit

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Key points

  • Despite a good safety record, respiratory complications are a major cause of morbidity and mortality in pediatric anesthesia.

  • 1 in 10 children present with 1 or more respiratory complications during their stay in the PACU.

  • The risk factors can be divided into patient factors, surgical factors, and factors caused by anesthesia management.

  • Rapid recognition of respiratory complications in the PACU and appropriate treatment strategies are essential to avoid hypoxia.

Definitions and signs of PRAE

PRAE in the PACU include apnea, bronchospasm, laryngospasm, severe persistent coughing, oxygen desaturation, and stridor/postextubation croup, with the following definitions10:

  • 1.

    Laryngospasm: complete airway obstruction associated with muscle rigidity of the abdominal and chest walls. Warning signs for the occurrence of laryngospasm are cough, breath holding, and straining in inspiration and expiration.

  • 2.

    Bronchospasm: increased respiratory effort, particularly during expiration, and wheeze on

Incidence of PRAE

Recent data in our institution have shown that 1 in 10 children in the PACU present with 1 or more PRAE.3 Although the incidence of bronchospasm and laryngospasm is low in the PACU (≤1%), 5% of children suffer from severe persistent coughing or desaturation (SpO2 <95%).3 Airway obstruction, which could be relived by simple airway maneuvers, was found in 1% of children in our institution independent of the presence of respiratory risk factors, whereas stridor was found mainly in high-risk

Severity and outcome of respiratory complications

Potential complications of PRAE in the PACU are negative pressure pulmonary edema, prolonged oxygen requirements, prolonged hospital stay, behavioral problems, need for reintubation, need for admission to the intensive care unit (ICU)/neonatal ICU (NICU), cardiac arrest, permanent brain damage, and death. Most reintubations and nearly half of all the unplanned postoperative admissions to ICU are related to PRAE, the remaining mainly for surgical reasons.14, 15 Most PRAE resulting in permanent

Adenotonsillectomy

Children undergoing ENT surgery, particularly adenotonsillectomy, have an increased incidence of PRAE,3, 4, 67 in particular oxygen desaturations and airway obstruction.68, 69

Not only does the operation on the upper airway cause postoperative swelling, but these children also have a high incidence of obstructive sleep apnea syndrome, which is often the primary reason for surgery. It is therefore common practice in many institutions to monitor these children, particularly if they also show

Drugs

Most anesthetic drug-related PRAE are caused by the mechanisms of reduced respiratory drive or impaired respiratory muscle function, leading to hypoventilation, atelectasis, and hypoxia. Rarely, anesthetic drugs can lead to allergic or nonallergic bronchoconstriction.

Infrastructure and Organization

Because children have high oxygen demands, they are particularly vulnerable to hypoxemia should a PRAE occur. However, many pediatric PACUs are solely staffed by nurses, without an attending anesthesiologist in the unit. The availability of medical backup in the PACU as well as the nurse/patient ratio varies between centers. Therefore, in anticipation of potential PRAE, regular training of the staff in rapid recognition and knowledge of the cause and treatment of PRAE in the PACU is vital.21

Acknowledgments

I thank Professor Adrian Regli, Intensive Care Unit, Fremantle Hospital, Perth, Australia for his valuable input into this article.

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    • Development of an Evidence-Based Pediatric Preoperative Risk Assessment Checklist

      2022, Journal of Perianesthesia Nursing
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      This collaborative policy statement with the American Academy of Pediatrics (AAP) and the American Society of Anesthesiologists (ASA) was a culmination of the past 50 years of published studies that focused on the following: credentialing by administrators for appropriate competent providers; identifying children with pediatric risk factors; ensuring age and size appropriate equipment; recommending medical and nursing pediatric competencies for surgeons, anesthesiologists, operating room nurses, and PACU nurses; and foremost, providing a safe quality perioperative care environment for patients and families.2,6 Multiple anesthesia and pediatric research studies have identified independent PPRF that are associated with PACU respiratory complications, or PRAE, and include ASA-Physical Status (ASA-PS) II, III, age, gender, airway comorbidities, syndromes, anomalies, pulmonary comorbidities, African American ethnicity, obesity, neurologic comorbidities, cardiac comorbidities and surgeries that are in close proximity to the airway.2-6,8-26 The ASA-PS clinical scoring system provides a measure to evaluate the patient's preoperative physical condition and/or functional state.

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    Funding: B.S. von Ungern-Sternberg is partly funded by the Princess Margaret Hospital Foundation and Woolworths Australia.

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