Recent Pediatric Anesthesia Mortality/Morbidity trends and predictors in Rawanda
Moris Baluku MD Kabale University, Uganda – recent graduate of the WFSA/PATA - Pediatric Anesthesia Fellowship in Uganda and Faye M Evans MD Boston Children’s Hospital
In 2014, during my (MB) internship training, I (MB) had the opportunity to work with a wonderful pediatric surgeon, Dr. Situma Martin. We had not been paid our internship allowances for three months. While assisting him in a procedure one afternoon, he quoted a then-popular telecom advert: “What do crocodiles eat?”. My reply was they ate interns' allowances. Unfortunately, Dr. Situma Martin died two years ago.
Health systems, if not well managed, are potentially crocodiles whose victims are the most vulnerable patients, such as children. There has been a rapid evidence-based evolution of pediatric anesthesia practices. Unfortunately, implementing these practices has been challenging in some areas of the world, especially those that are lower-resourced.
In one of the early landmark prospective observational studies exploring perioperative pediatric anesthesia mortality and morbidity, Cohen et al. reported that 35% of pediatric perioperative cases had a risk of either a major or minor anesthesia-related adverse event.1 Not surprisingly, neonates appeared to have the greatest risk of adverse events and death. This reported risk is quite high and a bit unnerving for families trusting you with their child’s care. While these numbers have reportedly improved in higher-resourced settings, what about in low- and middle-income countries where 90% of the world's children under 16 live? In Sub-Saharan Africa, about 85% of these children have been estimated to require surgery before the age of 16.2,3 Has the incidence of anesthesia-related events in pediatric patients changed since the 1980s when Cohen’s study was conducted?
In today's Pediatric Anesthesia Article of the Day, Nizeyimana et al. report on the perioperative anesthesia-related complications in children in Rwanda. The study was conducted in three public tertiary hospitals in a low-income country in East Africa. It provides a glimpse of the progress in a lower-resourced setting.
Original Article
Nizeyimana F, Skelton T, Bould MD, Beach M, Twagirumugabe T. Perioperative Anesthesia-Related Complications and Risk Factors in Children: A Cross-Sectional Observation Study in Rwanda. Anesth Analg. 2024 May 1;138(5):1063-1069. doi: 10.1213/ANE.0000000000006641. Epub 2023 Aug 15. PMID: 37678238.
This observational study aimed at estimating the prevalence of perioperative anesthesia-related adverse events and exploring potential risk factors among pediatric surgical patients in public referral hospitals in Rwanda. Context is everything, and it is important to recognize that “Health care is highly contextual. Important factors differ markedly between different jurisdictions, including the staffing, training, and supervision of health care providers, availability of essential drugs and equipment, available information technology, health system financing, health system governance, and other complex systems that support perioperative care.” No previous study has explored perioperative mortality or the perioperative complications of pediatric surgery in Rwanda.4
This study enrolled 354 patients; 69% had ASA I, and 65% had elective surgery. Three percent (11/354) suffered a cardiac arrest within 24 hours of surgery, and 6 of these patients died. Six (1.7%) suffered an intraoperative cardiac arrest, 2 (0.6%)of whom died intraoperatively. In the PACU, 6 (1.8%) suffered a postoperative cardiac arrest, 5 of whom (1.5%) died in the PACU. One child had both an intraoperative cardiac arrest and then a cardiac arrest in PACU but survived. Eighty-nine children (25.1%) had an intraoperative adverse event, whereas 67 (20.6%) had an adverse event in PACU. A review of the cases where cardiac arrest or death occurred indicated that there were significant lapses in the expected standard of care. On univariate analysis, the only factor found to be associated with cardiac arrest/ death was the infant being <1 week. The case series nicely details contextual issues that could be commonly found in a low-resource environment, such as inconsistent availability of essential drugs, equipment, and appropriately skilled staff.5
The findings of Nizeyimana’s study, done eight years ago but now being reported, are surprisingly comparable to those in the 1980s and this year’s findings from the observational cohort study of the outcomes after surgery for children in Africa (ASOS – Paeds). This study from Rwanda and the recently published African Surgical Outcomes Study-ASOS-Paeds found perioperative mortality rates of 2.1% and 2.3%, respectively, 10-fold that in high-income countries.4,6 Similar to previous studies, respiratory and cardiovascular events were more prevalent than other complications. Newton et al., in a prospective cohort study of 24 hospitals in Kenya, reported 7-day perioperative mortality of more than 100 times higher than in a high-resource setting. Practically, Nizeyimana could only collect outcome data within the first twenty-four hours of surgery compared to 30 days in the ASOS – Paeds Study and seven days in the study from Kenya. Would the rates have been higher had it been collected for 30 days? Probably yes. The authors pointed out a similar limitation.
At one of the author’s (MB) hospital, Kabale Regional Referral Hospital in Uganda, deaths in the postoperative period are twice those in the first 24 hours following surgery. The lack of age-appropriate monitors and intermittent monitoring means some observations were missed or, to an extent, not fully appreciated. This has implications on time to intervene, hence reducing the success rate with resuscitation and, secondly, failure to observe some adverse events. For example, dysrhythmias, besides bradycardia, cannot be recognized with intermittent ECG monitoring.
Interestingly, ASA physical status, urgency of surgery, and anesthetic technique were not found to be predictors of complications, unlike other previous studies. 7,8
Does regional anesthesia have a role in reducing overall perioperative complications and improving outcomes? A sub-group analysis would have been helpful, especially with the benefit of reducing airway instrumentation in cases where regional anesthesia is sufficient as a sole technique.
A short study duration (7 months) leading to a small sample size could not allow for enough observation of rare occurrences. Risk adjustment over time would have helped to appreciate any improvements in anesthesia safety had the study period been longer.
The authors make a critical statement that there were no pediatric anesthesiologists at the time of the study. Currently, there are now three pediatric anesthesiologists in Rwanda. Many improvements in pediatric anesthesia services will likely have occurred since this study was performed. The referral system has also improved. However, the findings from the recently published ASOS – Paeds study generally point to a region still at the tail end of global achievements in anesthesia safety.
While there have been significant improvements in anesthesia quality and safety, this study brings to reality the global disparity that exists and the need for concerted efforts in training, advocacy, collaboration, and health funding to close the existing gap.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Cohen MM, Cameron CB, Duncan PG. Pediatric Anesthesia Morbidity and Mortality in the Perioperative Period. Anesthesia Analg 1990;70:160.
2. Bickler SW. Surgical services for children in developing countries. 2016:1–7.
3. Bickler SW, Telfer ML, Sanno-Duanda B. Need for Paediatric Surgery Care in an Urban Area of the Gambia. Trop Dr 2003;33:91–4.
4. Nizeyimana F, Skelton T, Bould MD, Beach M, Twagirumugabe T. Perioperative Anesthesia-Related Complications and Risk Factors in Children: A Cross-Sectional Observation Study in Rwanda. Anesthesia Analg 2023.
5. Gray R, Cronjé L, Kalipa M, Lee C, Evans F. Paediatric anaesthesia care in Africa: challenges and opportunities. South Afr J Anaesth Analgesia 2022;28:4–6.
6. Torborg A, Meyer H, Fiky ME, Fawzy M, Elhadi M, Ademuyiwa AO, Osinaike BB, Hewitt-Smith A, Nabukenya MT, Bisegerwa R, Bouaoud S, Abdoun M, Adib ARE, Belachew FK, Gebre M, Taye DB, Kechiche N, Fadalla T, Abdallah B, Chaibou MS, Nyarko MYA, Ki KB, Shalongo S, Mulwafu W, Thomson E, Traore MM, Ndonga A, Bittaye M, Samateh AL, Munlemvo DM, et al. Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study. Lancet (Lond, Engl) 2023;403:1482–92.
7. Newton MW, Hurt SE, McEvoy MD, Shi Y, Shotwell MS, Kamau J, Nabulindo S, Ngumi ZWW, Sandberg WS, Sileshi B. Pediatric Perioperative Mortality in Kenya. Anesthesiology 2020;132:452–60.
8. Gonzalez LP, Pignaton W, Kusano PS, Módolo NSP, Braz JRC, Braz LG. Anesthesia-related mortality in pediatric patients: a systematic review. Clinics 2012;67:381–7.