Neuromorbidity can be avoided
Analyses of pediatric closed malpractice claims regularly describe the causal relationship between anesthetic practice and morbidity as well mortality in previously healthy children.1 Partial brain damage, persistent vegetative state, brain death or even death represent only the most catastrophic outcomes. These merely represent the ‘tip of the iceberg’ as they do not include incidents and ‘near misses’ that do not result in lawsuits.
Conduct of anesthesia matters
Sub-clinical cerebral damage caused by peri-operative adverse events (including peri-operative cardiac arrest, prolonged cardio-respiratory depression or brain swelling due to free water administration in children undergoing anesthesia) is frequently a result of the poor conduct of anesthesia. This is not necessarily disclosed to parents, investigated or reported. 2
Complications in pediatric anesthesia are directly related to the (in-) experience of the anesthesiologist in charge. Occasional pediatric anesthetic practice (less than 100 cases per year per anesthesiologist) is associated with a 5 times increased risk of complications when compared to regular practice (more than pediatric 200 cases per year).3
Hypotension and/or hypocapnia lead to cerebral hypoperfusion and brain injury. 4 5 However, hypotension in neonates and small children during anesthesia is often tolerated and even accepted. Treatment thresholds for neonatal systolic hypotension vary significantly, for example between North America (45.5 mmHg) and the internationally recommended threshold of 60 mmHg. 6 7 Whether this explains differences in reported retrospective outcomes is speculative. 5 8 9 10 11 12 13
Younger and smaller children are at high risk of peri-operative hypoxemia due to their relatively higher oxygen demand and lower oxygen reserves. Prolonged hypoxic episodes frequently occur in the peri-operative period and are common at induction of anesthesia for emergency procedures. 14 15 16
The impact of peri-operative use of hypotonic fluids on cerebral damage is not considered in retrospective human outcome studies. Profound hyponatremia results in seizure activity, coma and death. Only the most severe cases and series are reported. 17 18 19 20 Moderate peri-operative hyponatremia may cause sub-clinical neuronal damage detectable only years after surgery with sophisticated neuro-cognitive testing.
The Safetots.org initiative highlights the known peri-operative causes for cerebral morbidity in young children.
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