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


RESULTS
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).


CONCLUSIONS
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.


BACKGROUND
Department of Anaesthesia, Princess Margaret Hospital for Children, Swiss Foundation for Grants in Biology and Medicine, and the Voluntary Academic Society Basel.
von Ungern-Sternberg
Britta S
BS
Department of Anaesthesia, Princess Margaret Hospital for Children, Perth, WA, Australia. bvonungern@uhbs.ch
Boda
Krisztina
K
Chambers
Neil A
NA
Rebmann
Claudia
C
Johnson
Chris
C
Sly
Peter D
PD
Habre
Walid
W
D000280:Administration, Inhalation; D000293:Adolescent; D000402:Airway Obstruction / Q000209:etiology; D000704:Analysis of Variance; D000768:Anesthesia, General / Q000009:adverse effects* / Q000379:methods*; D018681:Anesthetics, General / Q000008:administration & dosage* / Q000009:adverse effects*; D001249:Asthma / Q000150:complications; D001986:Bronchial Spasm / Q000209:etiology; D002648:Child; D002675:Child, Preschool; D003371:Cough / Q000209:etiology; D005260:Female; D006801:Humans; D006967:Hypersensitivity / Q000150:complications; D007223:Infant; D007262:Infusions, Intravenous; D007826:Laryngismus / Q000209:etiology; D008297:Male; D008487:Medical History Taking; D011446:Prospective Studies; D012120:Respiration Disorders / Q000209:etiology* / Q000235:genetics; D012135:Respiratory Sounds / Q000209:etiology; D012141:Respiratory Tract Infections / Q000150:complications; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D014028:Tobacco Smoke Pollution / Q000009:adverse effects
D018681:Anesthetics, General; D014028:Tobacco Smoke Pollution