Christensen Robert E, Nause-Osthoff Rebecca C, Waldman Jeffrey C, Spratt Daniel E, Hearn Jason W D
Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan.
US Anesthesia Partners Colorado, Greenwood Village, Colorado.
Paediatr Anaesth. 2019 Mar;29(3):265-270. doi: 10.1111/pan.13567. Epub 2019 Jan 29.
Radiation therapy in pediatric patients often requires anesthesia and poses environmental challenges. Monitoring must be done remotely to limit radiation exposure to the provider. Airway access can be limited by masks or frames. Care is often delivered in relatively inaccessible locations in the hospital. While individual institutions have reported their outcomes, this case series aims to review a multicenter registry of significant adverse events and make recommendations for improved care.
Wake Up Safe: The Pediatric Quality Improvement Initiative maintains a multisite, voluntary registry of pediatric perianesthetic significant adverse events. This was queried for reports from radiation oncology from January 1, 2010 to May 10, 2018. The database contained 3,379 significant adverse events from approximately 3.3 million anesthetics. All 33 institutions submitted data on a standardized form to a central data repository (Axio Research, Seattle Washington). Prior to each significant adverse events case submission, three anesthesiologists who were not involved in the event analyzed the event using a standardized root cause analysis method to identify the causal or contributing factor(s).
Six significant adverse events were identified. In three, incorrect programming of a propofol infusion resulted in overdose. In case one, the 3-year-old female became hypotensive, requiring vasopressors and volume resuscitation. In the second, the 2-year-old female experienced airway obstruction and apnea requiring chin lift. In case three, the child suffered no consequences despite a noted overdose of propofol infusion. In case four, a 2-year-old female with recent respiratory infection suffered laryngospasm during an unmonitored transport to the recovery area. She developed profound oxygen desaturation with bradycardia treated with succinylcholine and chest compressions. In case five, a 6-year-old former premature child suffered laryngospasm at the conclusion of mask creation under general anesthesia with a laryngeal mask airway. The radiation mask delayed recognition of copious secretions. Finally, in case six, a 6-year-old undergoing stereotactic radiosurgery in a head halo suffered bronchospasm and unintended extubation during therapy which required multiple attempts at reintubation by multiple providers ultimately requiring cancellation of the treatment and transport to the intensive care unit.
There were few radiation oncology significant adverse events, but analysis has led to the identification of several specific opportunities for improvement in pediatric anesthesia for radiation oncology.
儿科患者的放射治疗通常需要麻醉，并且带来环境方面的挑战。必须进行远程监测，以限制医护人员的辐射暴露。气道通路可能会受到面罩或框架的限制。护理工作常常在医院相对难以到达的地点进行。虽然个别机构报告了他们的结果，但本病例系列旨在回顾一个多中心的重大不良事件登记册，并为改善护理提出建议。
“安全苏醒：儿科质量改进倡议”维护了一个多地点的、关于儿科围麻醉期重大不良事件的自愿登记册。查询了2010年1月1日至2018年5月10日期间放射肿瘤学的报告。该数据库包含来自约330万例麻醉的3379起重大不良事件。所有33家机构都以标准化表格向中央数据存储库（华盛顿州西雅图的Axio Research）提交了数据。在每起重大不良事件病例提交之前，三名未参与该事件的麻醉医生使用标准化的根本原因分析方法对该事件进行分析，以确定因果或促成因素。
确定了6起重大不良事件。其中3起，丙泊酚输注程序错误导致用药过量。在病例一中，3岁女性出现低血压，需要使用血管加压药和液体复苏。在第二例中，2岁女性出现气道梗阻和呼吸暂停，需要抬下巴。在病例三中，尽管丙泊酚输注明显过量，但患儿未出现后果。在病例四中，一名近期有呼吸道感染的2岁女性在未经监测的转运至恢复区过程中发生喉痉挛。她出现严重的氧饱和度下降和心动过缓，用琥珀酰胆碱和胸外按压进行治疗。在病例五中，一名6岁的 former premature child 在使用喉罩气道全身麻醉下制作面罩结束时发生喉痉挛。放射治疗面罩延迟了对大量分泌物的识别。最后，在病例六中，一名6岁儿童在头戴头环进行立体定向放射外科手术时，在治疗过程中发生支气管痉挛和意外拔管，多名医护人员多次尝试重新插管，最终需要取消治疗并转运至重症监护病房。
放射肿瘤学方面的重大不良事件很少，但分析已导致确定了儿科放射肿瘤学麻醉中几个具体的改进机会。
