Morbidity and mortality after anesthesia in large cohort of infants less than 60 weeks post conceptual age. The NECTARINE study
Lynne Maxwell, MD
As promised we are increasing the PAAD’s writing/reviewing crew and the journals we cover. Today is Lynne Maxwell’s first PAAD solo voyage and going forward she will be the primary reviewer of the British J of Anesthesia and Regional Anesthesia and Pain Management. For those of you who don’t know her, Lynne, my sister from another mother, recently retired as a professor of anesthesiology and critical care medicine at the Children’s Hospital of Philadelphia and was the 2016 AAP Robert M. Smith award winner. We plan to have an editorial meeting for those of you who are interested in being reviewers at the fall SPA/ASA meeting. More details of that meeting to follow. Myron Yaster MD
Nicola Disma, 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) Br J Anaesth; 2021 Jun;126(6):1157-1172. PMID: 33812668
NECTARINE (NEonate-Children sTudy of Anaesthesia pRactice IN Europe) was a prospective, observational, multicenter cohort study of neonatal and infant anaesthesia funded through the European Society of Anaesthesiology and Intensive Care (ESAIC) clinical trial network. It was designed to provide information on morbidity and mortality related to anesthesia in patients under 60 weeks postconceptual age. 165 centers from 31 European countries collected data on 5609 patients undergoing 6542 procedures during a 3 month period between March 2016 and January 2017.
Unlike previous reports of anesthetic-related morbidity and mortality in pediatric patients such as the two publications from the pediatric perioperative cardiac arrest (POCA) registry1,2, which documented cardiac arrests in children (289 and 193 respectively) undergoing anesthesia voluntarily reported from a small number of institutions (63 and 79 respectively) over a period of years, the NECTARINE group comprised 165 centers reported medical interventions for critical events related to excessive deviations in physiologic parameters (hypotension, desaturation) agreed upon through a consensus determination process among the study coordinators prior to data collection. Data from 6542 procedures 5609 infants with a mean post-conceptual age at birth of 36.2 weeks were collected.
This study was conceived to examine the incidence of intervention-triggering physiologic deviations under anesthesia in the demographic group shown by previous studies of anesthetic morbidity and mortality to be most vulnerable (infants < 63 days of birth including those born prematurely).2,3,4 The study was undertaken following the previous European study of anesthesia-related critical events in the general pediatric population,3 which was not designed to capture detailed information about the complex pre-anesthesia medical conditions of small infants. The research question to be explored included the incidence of significant perioperative medical interventions or treatments, what factors triggered an intervention, whether there are factors that can predict the need for various interventions, morbidity and mortality at 30 and 90 days after neonatal anesthesia in Europe, and what is the current state of routine clinical practice of neonatal anesthesia in Europe.
When reading this study, it is essential to understand the intensive consensus process undertaken by the investigators prior to the commencement of data collection, in which the elements of demographic, medical history, physiologic data and medication administration to be collected were agreed upon. The reader should examine the supplementary material in Appendix A which includes detailed medical information on the patients and the protocol for the study which established the commonly agreed upon definitions for all the data elements collected. This agreement allows for greater consistency of reporting from such a large number of study sites. One of the study’s limitations is that the data reports only interventions in response to a critical event rather than interventions provided to prevent the occurrence of such an event. Critical events that were tolerated rather than acted upon may not have been reported as physiologic data were self-reported not gathered from an electronic database.
Neonates with pre-existing medical co-morbidities and need for intensive care and/or mechanical ventilation had a higher incidence of critical events requiring intervention. 30-day mortality was comparable with prior reports, with increased risk related to degree of physiologic instability, need for preoperative intensive support, and after hours surgery, with the incidence of critical events and mortality being higher in infants anesthetized before 32 weeks post-menstrual age. Increased morbidity and mortality were related to the concomitant occurrence of hypotension, hypoxemia and anemia. For the entire group the incidence of perioperative cardiac arrest (12.2/10,000) was lower than that reported by Wake Up Safe (27.3/10,000) although the Wake Up Safe population included infants up to 6 months of age. Long term follow-up after 90 days was not reported including no information about neurodevelopmental outcome.
The authors and participating institutions are to be congratulated on an admirable and labor-intensive collaborative effort to generate these data and we look forward to the results of future efforts by this group.
Lynne Maxwell, MD
1. Morray JP, Geiduschek JM, Ramamoorthy C et al. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology 2000; 93: 6-14
2. Bhananker SM, Ramamoorthy C, Geiduschek JM et al. Anesthesia-related cardiac arrest in children: update from the pediatric cardiac arrest registry. Anesth Analg 2007; 105: 344-50
3. 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; 5:412-25
4. Christensen RE, Haydar B, Voepel-Lewis TD. Pediatric cardiopulmonary arrest in the postanesthesia care unit, rare but preventable: analysis of data from Wake up Safe, the pediatric anesthesia quality improvement initiative. Anesth Analg 2017; 124:1231-6