Pediatric patients with an American Society of Anesthesiologists (ASA) physical status classification of at least III are at risk for postoperative complications and mechanical ventilation, even when undergoing low-risk procedures, researchers have concluded.
Identifying these patients will go a long way toward ensuring they receive targeted preventive interventions, particularly with respect to pulmonary and nutritional status.
“We don’t have a lot of data regarding perioperative risk stratification in pediatric patients,” said Anthony Longhini, MD, a resident at McGaw Medical Center of Northwestern University, in Chicago. “Many studies have focused only on adults, or aren’t focused specifically on anesthetic-related complications.
“So the goal of this study was to determine the incidence of perioperative complications in pediatric patients undergoing low-risk surgery, which we defined as skin or soft tissue surgery with an expected blood loss of less than 20 mL.”
Postoperative Complications Counted
The researchers hypothesized that patients with greater illness severity would have an increased incidence of complications.
To help answer these questions, Dr. Longhini and his colleagues reviewed data from 6,851 patients who underwent such procedures at the institution between 2011 and 2014. The primary outcome was a composite of 10 postoperative complications, including wound complications, infectious complications, pulmonary complications and bleeding requiring transfusion. “And then we also looked at secondary outcomes of postoperative mechanical ventilation and readmission,” he added.
Univariable analyses were performed to identify associations between preoperative characteristics and postoperative complications, readmission and postoperative mechanical ventilation. Multivariable logistic regression models also were created to identify independent predictors for postoperative complications and readmission.
At the 2016 annual meeting of the International Anesthesia Research Society (abstract S-241), Dr. Longhini revealed that 169 postoperative complications occurred in 152 patients (2.22%), the majority of which were wound related or postoperative mechanical ventilation.
“In our univariable analysis, we saw an association between male gender, general surgery, otolaryngology, plastic surgery, ASA classification greater than II, nutritional deficiency, preexisting cardiac and neurologic disease, and postoperative complications,” Dr. Longhini said. Multivariable analysis revealed a number of risk factors for increased postoperative complications, including ASA classification of at least III, nutritional deficiency, pulmonary disease and neurologic disease.
Significant risk factors for postoperative mechanical ventilation included ASA classification of at least III, nutritional deficiency, cardiac disease and pulmonary disease. “We also looked at unplanned readmissions, which occurred in 41 patients [0.6%]. Having a pulmonary complication was predictive of readmission.”
Low-Risk Procedures in High-Risk Children
Preventing these sequelae is as easy as targeting specific interventions in high-risk children, even when they’re undergoing low-risk procedures. “Nutritional deficiency is a modifiable risk factor than can be identified preoperatively,” Dr. Longhini noted. “And if a patient has a nutritional deficiency, we should not rush to perform the surgery, even if it’s superficial.”
“One of the other things to think about is preoperative mechanical ventilation,” said Olubukola O. Nafiu, MD, assistant professor of anesthesiology at the University of Michigan Health System, in Ann Arbor. “We know that’s a very strong predictor of postoperative mechanical ventilation. These could be patients who are ventilated at home prior to surgery.”
“With respect to wound infection, it’s a really big issue, and the incidence in general surgery is much higher than you’d think,” commented Myron Yaster, MD, the Richard J. Traystman Distinguished Professor of Anesthesiology/Critical Care Medicine and Pediatrics at Johns Hopkins University School of Medicine, in Baltimore. Patients at higher risk for these complications can undergo interventions such as glucose control, maintenance of normothermia, optimization of tissue oxygenation and appropriate use of antibiotic prophylaxis.
All told, these results demonstrate that even low-risk procedures bear the potential for complications, ventilation and readmission in high-risk children. “The problem here is that we are doing more and more procedures in the ambulatory setting,” commented co-investigator Santhanam Suresh, MD, the Arthur C. King Professor in Anesthesiology at Northwestern University Feinberg School of Medicine, in Chicago. “That’s one of the reasons why we were interested in looking at these data. Because as we battle with our surgeons about which patients should be seen in a freestanding ambulatory center, these data demonstrate that some of these patients should be done in the main hospital.”
As the study’s principal investigator, Eric C. Cheon, MD, instructor in anesthesiology at Northwestern University Feinberg School of Medicine, commented, anesthesiologists’ purview cannot be limited solely to the operating room but must also include the patient’s postoperative course. “These results highlight this reality, as a significant portion of patients undergoing low-risk surgery nonetheless had legitimate postoperative complications,” Dr. Cheon said.
Dr. Longhini echoed these sentiments. “From this we would recommend that patients who are greater than ASA II undergo surgery at a location where postoperative mechanical ventilation can be provided,” he advised.
Session moderator J. Lance Lichtor, MD, professor of anesthesiology and pediatrics at Yale University, in New Haven, Conn., agreed that these patients need to be vigilantly cared for. “I want to make the point that children who are ASA level II or greater should be cared for by a pediatric anesthesiologist,” he said.