Predicting perioperative risk to pediatric patients
Jayant K Deshpande, MD MPH and Myron Yaster, MD
Today, December 7th, is Pearl Harbor Day, “a date which will live in infamy.” On December 7, 1941 “the United States of America was suddenly and deliberately attacked by the naval and air forces of the Empire of Japan." America declared war on Japan and subsequently on Nazi Germany, and thus America entered into World War II. If you can take a moment of silent reflection to remember those who gave their lives so that unspeakable evil could be defeated and we could live in freedom…
Today’s PAAD is all about predicting pediatric perioperative anesthetic risk. So, before reading today’s PAAD, what is the anesthetic perioperative risk in healthy ASA 1-2 patients? What do you tell parents? If you had to guess is it higher, lower, or about the same risk of injury on a trampoline? I had to look this up and found the answer in the most unlikely of places. Myron Yaster MD
Original article
Virginia E Tangel, Stephan D Krul, Robert Jan Stolker, Wichor M Bramer, Jurgen C de Graaff, Sanne E Hoeks. Perioperative Mortality in Pediatric Patients: A Systematic Review of Risk Assessment Tools for Use in the Preoperative Setting. Anesthesiology. 2022 Nov 1;137(5):555-567. PMID: 36069894
Editorial
Laszlo Vutskits, Andrew Davidson. Predicting Perioperative Mortality in Children: Academic Endeavor or Clinical Value? Anesthesiology. 2022 Nov 1;137(5):526-528. PMID: 36264088
Parent: “Doctor, what are the risks of my child undergoing this surgery?”
Anesthesiologist: “Well, anesthesia has come a long way over the past 30 years. The risk of anesthesia is almost negligible.”
Parent: “Tell me the truth…what are the risks of this surgery?”
Anesthesiologist: “You should speak with your surgeon about the risks of surgery.”
This nearly daily exchange feels quite unsatisfactory to the parents and to us as anesthesiologists. But do we really know how to gauge the perioperative risks to a particular child undergoing a particular procedure?
In a recent PAAD, we talked about going beyond safety in anesthesia to focus on defining and improving quality because of the diminutive the anesthesia risks. [see PAAD July 21, 2002: “Benchmarking Quality”1 https://ronlitman.substack.com/p/benchmarking-quality]
Yet, our patients and families have real concerns for which we often give incomplete and unsatisfying answers. The published overall perioperative risk for children ranges from 0.3-1.5% - that’s about 1 child in 100 at risk of mortality or significant morbidity. For the average children’s anesthesia practice which conducts about 10,000 anesthetics, that’s 100 children who have a significant perioperative risk of mortality!
In a recent edition of Anesthesiology, Tangel et al.2 present their findings of a systematic review of perioperative risk assessment tools predicting mortality that have been previously published for pediatric patients. Of the hundreds of articles published, they found only 10 that met inclusion criteria. Nine of these had only internal validation and 1 was an external validation of a published tool. Many have high or unclear risks of bias. Seven of the articles relied on data from the American College of Surgeons’ NSQIP database and some used data collected in the intra- and post-operative periods.3-5 The authors conclude, “There is an abundance of risk prediction scores available for the pediatric anesthesiologist to use in the preoperative setting. Before any large-scale adaptation of a particular score, prospective, fully independent external validations and further refinement of existing scores need to occur [italics added]—especially in non-US and low-resource settings.”2
An editorial by Vutskits and Davidson6 accompanies this article by Tangel and colleagues. The editorial comments on the challenges of creating useful perioperative risk prediction tools for pediatric patients. They remind us that “…the development of prediction scores focusing on mortality is still the most feasible, reliable, and straightforward approach.”6 They also caution that, “…that validation does not automatically mean clinical usefulness. Once validation of a model is reasonably complete, the next important step should be to evaluate if it indeed influences physician behavior and patient outcome.”6
So, more work needs to be done before we can give the patient and family a clear answer to their question about the risks of a procedure. In the meantime, an empathetic approach and adherence to best practices by all involved in the perioperative care of the child will create the best chance of a good outcome. Jay and I wonder how you deal with this issue in your daily practice. Please forward your responses to me (Myron) and I’ll post in a future PAAD reader response.
References
1. Olbrecht VA, Uffman JC, Morse RB, Engelhardt T, Tobias JD. Setting a universal standard: Should we benchmark quality outcomes for pediatric anesthesia care? Paediatric anaesthesia. Aug 2022;32(8):892-898. doi:10.1111/pan.14474
2. Tangel VE, Krul SD, Stolker RJ, Bramer WM, de Graaff JC, Hoeks SE. Perioperative Mortality in Pediatric Patients: A Systematic Review of Risk Assessment Tools for Use in the Preoperative Setting. Anesthesiology. Nov 1 2022;137(5):555-567. doi:10.1097/aln.0000000000004369
3. Ji D, Goudy SL, Raval MV, Raol N. Pediatric Surgical Risk Assessment Tools: A Systematic Review. J Surg Res. Feb 2019;234:277-282. doi:10.1016/j.jss.2018.09.051
4. Kraemer K, Cohen ME, Liu Y, et al. Development and Evaluation of the American College of Surgeons NSQIP Pediatric Surgical Risk Calculator. J Am Coll Surg. Nov 2016;223(5):685-693. doi:10.1016/j.jamcollsurg.2016.08.542
5. Nasr VG, Staffa SJ, Zurakowski D, DiNardo JA, Faraoni D. Pediatric Risk Stratification Is Improved by Integrating Both Patient Comorbidities and Intrinsic Surgical Risk. Anesthesiology. Jun 2019;130(6):971-980. doi:10.1097/aln.0000000000002659
6. Vutskits L, Davidson A. Predicting Perioperative Mortality in Children: Academic Endeavor or Clinical Value? Anesthesiology. Nov 1 2022;137(5):526-528. doi:10.1097/aln.0000000000004392