Perioperative Komplikationen in der Kinderanästhesie

Kritische Ereignisse sind in der Kinderanästhesie nach wie vor häufiger als bei erwachsenen Patienten. Sicherheit und Outcome der behandelten Kinder ist entscheidend davon abhängig, wie gut diese kritischen Ereignisse gemanagt werden. Dieser Beitrag beschreibt häufige perioperative Komplikationen und zeigt Möglichkeiten zur Risikoabschätzung und Optimierung auf, die dazu beitragen können, schwerwiegende und langfristige Folgen zu reduzieren.

Abstract

Perioperative complications are more frequent in younger children, especially under the age of 3 years and in infants. The anatomy and physiology of children cause more respiratory adverse events compared to adult patients. Respiratory adverse events account for 60% of all anesthetic complications. Main risk factors for respiratory adverse events are upper respiratory tract infections. Keeping the airway management as noninvasive as possible helps prevent major complications.

Perioperative hypotension can compromise cerebral oxygenation, especially when hypocapnia and anemia are present. Congenital heart disease leads to a higher cardiovascular adverse event rate and should be diagnosed preoperatively whenever possible.

Venous and arterial cannulation is more challenging in children and complications are more frequent even for experienced practitioners. Ultrasound is an essential tool for peripheral venous access as well as for central venous catheterization.

Medication errors are more common in pediatric than in adult patients. Charts and electronic calculation of dosing can increase safety of prescriptions. Standardized storage of medications at all workplaces, avoiding look-alike medications in the same compartment and storing high-risk medications separately help prevent substitution errors.

Emergence delirium and postoperative nausea and vomiting (PONV) are the most frequent postoperative adverse events. For diagnosing emergence delirium, the PAED scale is a helpful tool. Prevention of emergence delirium by pharmacological and general measures plays a key role for patient outcome. Routine prophylaxis of PONV above the age of 3 years is recommended.

Frequency and severity of perioperative adverse events in pediatric anesthesia can be reduced by using algorithms and defined processes to allow for structured actions. Efficient communication and organization are mainstays for utilizing all medical options to reduce the risk of complications.

Kernaussagen

• Sowohl bei der peripheren Venenpunktion als auch bei der Anlage zentraler Venenkatheter ist die Sonografie das wichtigste Hilfsmittel.

• Respiratorische und kardiale Ereignisse sind die häufigste Ursache perioperativer kritischer Vorfälle.

• Invasive Atemwegssicherung und oberer Atemwegsinfekt sind Risikofaktoren für das Auftreten von Atemwegskomplikationen.

• Einen adäquaten Blutdruck aufrechtzuerhalten, ist wichtig für die Wahrung der zerebralen Perfusion.

• Fehler bei der Medikamentenapplikation sind vor allem auf Kommunikationsdefizite, nicht korrekte Dosisberechnungen oder Verdünnungen sowie Medikamentenverwechslung zurückzuführen.

• Im Aufwachraum sind das Emergence-Delir und postoperatives Erbrechen die häufigsten unerwünschten Ereignisse, die eine effektive Prävention erfordern.

• Kommunikation und standardisierte Prozesse sind wichtige Elemente zur Reduktion von Komplikationen.

Schlüsselwörter

Kinderanästhesie - perioperative Komplikationen - Patientensicherheit - Atemwegsmanagement - Medikamentenfehler

Keywords

pediatric anesthesia - perioperative complications - patient safety - airway management - medication errors

Publication History

Article published online:
01 September 2022

• Literatur

• 1 Habre W, Disma N, Virag K. et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med 2017; 5: 412-425
• 2 von Ungern-Sternberg BS, Boda K, Chambers NA. et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet 2010; 376: 773-783
• 3 MacLennan AI, Smith AF. An analysis of critical incidents relevant to pediatric anesthesia reported to the UK National Reporting and Learning System, 2006–2008. Paediatr Anaesth 2011; 21: 841-847
• 4 Hohn A, Machatschek JN, Franklin J. et al. Incidence and risk factors of anaesthesia-related perioperative cardiac arrest: A 6-year observational study from a tertiary care university hospital. Eur J Anaesthesiol 2018; 35: 266-272
• 5 Cuper NJ, de Graaff JC, van Dijk AT. et al. Predictive factors for difficult intravenous cannulation in pediatric patients at a tertiary pediatric hospital. Paediatr Anaesth 2012; 22: 223-229
• 6 Hackenberg K, Kabir K, Muller A. et al. Extravasation injuries of the limbs in neonates and children-development of a treatment algorithm. Dtsch Arztebl Int 2021; 118: 547-554
• 7 Van de Voorde P, Turner NM, Djakow J. et al. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161: 327-387
• 8 Schindler E, Schears GJ, Hall SR. et al. Ultrasound for vascular access in pediatric patients. Paediatr Anaesth 2012; 22: 1002-1007
• 9 Schindler E, Mikus M, Velten M. Central Venous Access in Children: Technique and Complications. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56: 60-68
• 10 Breschan C, Platzer M, Jost R. et al. Ultrasound-guided supraclavicular cannulation of the brachiocephalic vein in infants: a retrospective analysis of a case series. Paediatr Anaesth 2012; 22: 1062-1067
• 11 Bhananker SM, Ramamoorthy C, Geiduschek JM. et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg 2007; 105: 344-350
• 12 Tait AR, Malviya S, Voepel-Lewis T. et al. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology 2001; 95: 299-306
• 13 Templeton TW, Sommerfield D, Hii J. et al. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia – Part 2: Anesthesia-related risk and treatment options. Paediatr Anaesth 2022; 32: 217-227
• 14 Becke K. Children with respiratory infections – How and when to perform anesthesia. Anasthesiol Intensivmed Notfallmed Schmerzther 2014; 49: 162-167
• 15 Regli A, Becke K, von Ungern-Sternberg BS. An update on the perioperative management of children with upper respiratory tract infections. Curr Opin Anaesthesiol 2017; 30: 362-367
• 16 Lee LK, Bernardo MKL, Grogan TR. et al. Perioperative respiratory adverse event risk assessment in children with upper respiratory tract infection: Validation of the COLDS score. Paediatr Anaesth 2018; 28: 1007-1014
• 17 Hii J, Templeton TW, Sommerfield D. et al. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia – Part 1: Patient and surgical factors. Paediatr Anaesth 2022; 32: 209-216
• 18 Lee S, Reddington E, Koutsogiannaki S. et al. Incidence and risk factors for perioperative cardiovascular and respiratory adverse events in pediatric patients with congenital heart disease undergoing noncardiac procedures. Anesth Analg 2018; 127: 724-729
• 19 Drake-Brockman TF, Ramgolam A, Zhang G. et al. The effect of endotracheal tubes versus laryngeal mask airways on perioperative respiratory adverse events in infants: a randomised controlled trial. Lancet 2017; 389: 701-708
• 20 Fiadjoe JE, Nishisaki A, Jagannathan N. et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med 2016; 4: 37-48
• 21 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). Brit J Anaesth 2021; 126: 1157-1172
• 22 Else SDN, Kovatsis PG. A narrative review of oxygenation during pediatric intubation and airway procedures. Anesth Analg 2020; 130: 831-840
• 23 Beck CE, Rudolph D, Mahn C. et al. Impact of clear fluid fasting on pulmonary aspiration in children undergoing general anesthesia: Results of the German prospective multicenter observational (NiKs) study. Paediatr Anaesth 2020; 30: 892-899
• 24 Warner MA, Warner ME, Warner DO. et al. Perioperative pulmonary aspiration in infants and children. Anesthesiology 1999; 90: 66-71
• 25 Michelet D, Arslan O, Hilly J. et al. Intraoperative changes in blood pressure associated with cerebral desaturation in infants. Paediatr Anaesth 2015; 25: 681-688
• 26 Rhondali O, Andre C, Pouyau A. et al. Sevoflurane anesthesia and brain perfusion. Paediatr Anaesth 2015; 25: 180-185
• 27 McCann ME, Schouten AN. Beyond survival; influences of blood pressure, cerebral perfusion and anesthesia on neurodevelopment. Paediatr Anaesth 2014; 24: 68-73
• 28 Ringer SK, Ohlerth S, Carrera I. et al. Effects of hypotension and/or hypocapnia during sevoflurane anesthesia on perfusion and metabolites in the developing brain of piglets-a blinded randomized study. Paediatr Anaesth 2016; 26: 909-918
• 29 Weber F, Scoones GP. A practical approach to cerebral near-infrared spectroscopy (NIRS) directed hemodynamic management in noncardiac pediatric anesthesia. Paediatr Anaesth 2019; 29: 993-1001
• 30 Lynch J, Pehora C, Holtby H. et al. Cardiac arrest upon induction of anesthesia in children with cardiomyopathy: an analysis of incidence and risk factors. Paediatr Anaesth 2011; 21: 951-957
• 31 Nasr VG, DiNardo JA, Faraoni D. Development of a pediatric risk assessment score to predict perioperative mortality in children undergoing noncardiac surgery. Anesth Analg 2017; 124: 1514-1519
• 32 Flick RP, Sprung J, Harrison TE. et al. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients. Anesthesiology 2007; 106: 226-237
• 33 Carmosino MJ, Friesen RH, Doran A. et al. Perioperative complications in children with pulmonary hypertension undergoing noncardiac surgery or cardiac catheterization. Anesth Analg 2007; 104: 521-527
• 34 Saynhalath R, Alex G, Efune PN. et al. Anesthetic complications associated with Severe Acute Respiratory Syndrome Coronavirus 2 in pediatric patients. Anesth Analg 2021; 133: 483-490
• 35 Valverde I, Singh Y, Sanchez-de-Toledo J. et al. Acute cardiovascular manifestations in 286 children with multisystem inflammatory syndrome associated with COVID-19 infection in Europe. Circulation 2021; 143: 21-32
• 36 Feinstein MM, Pannunzio AE, Castro P. Frequency of medication error in pediatric anesthesia: A systematic review and meta-analytic estimate. Paediatr Anaesth 2018; 28: 1071-1077
• 37 Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI). Medikamentensicherheit in der Kinderanästhesie. 2. Aufl. 11/2021. Accessed May 02, 2022 at: http://www.awmf.org/leitlinien/detail/ll/001–033.html
• 38 Sachs AN, Avant D, Lee CS. et al. Pediatric information in drug product labeling. JAMA 2012; 307: 1914-1915
• 39 Luce V, Harkouk H, Brasher C. et al. Supraglottic airway devices vs tracheal intubation in children: a quantitative meta-analysis of respiratory complications. Paediatr Anaesth 2014; 24: 1088-1098
• 40 Aldecoa C, Bettelli G, Bilotta F. et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34: 192-214
• 41 Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology 2004; 100: 1138-1145
• 42 Locatelli BG, Ingelmo PM, Emre S. et al. Emergence delirium in children: a comparison of sevoflurane and desflurane anesthesia using the Paediatric Anesthesia Emergence Delirium scale. Paediatr Anaesth 2013; 23: 301-308
• 43 Lehmann V, Giest J, Wermelt J. et al. Pediatric emergence agitation. Anaesthesist 2015; 64: 373-380
• 44 Gan TJ, Belani KG, Bergese S. et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg 2020; 131: 411-448
• 45 Chauvin C, Schalber-Geyer AS, Lefebvre F. et al. Early postoperative oral fluid intake in paediatric day case surgery influences the need for opioids and postoperative vomiting: a controlled randomized trial. Br J Anaesth 2017; 118: 407-414