DOI: https://doi.org/10.21203/rs.3.rs-138101/v1
Introduction: Perioperative respiratory adverse events (PRAEs) are the most frequent complications in pediatrics which frequently result in morbidity and mortality. They are accountable for 75% of perioperative critical incidents and 33% of cardiac arrests. The occurrence and severity of PRAEs depends on the natures of surgery, anesthesia & patient’s status.
Objective: To assess the incidence and factors associated with PRAEs in general anesthesia among pediatric surgical patients at the University of Gondar and Tibebe-Ghion Comprehensive Hospital and Specialized Hospitals, Northwest Ethiopia, 2020.
Methods: After obtaining the ethical approval, a hospital-based prospective cross-sectional follow-up study was conducted among pediatric surgical patients who underwent variety of surgical operations. A total of 225 patients were included. The associations between independent variables and the outcome variables were determined at 95% CI with the Chi-squared test, Fisher–exact test, bivariate, and multivariate logistic regression. Hosmer-Lemeshow test was used to assess the goodness of fit. Variables with a p-value < 0.05 were considered significant.
Results: The incidence of PRAEs among 210 (93.3% response rate) pediatrics surgical patients was 26.2% (95% CI: 20.5, 30.9). A total of 129 episodes of PRAEs were observed. Most of the adverse events (89 (69.0%)) were occurred postoperatively. Desaturation was found to be the predominant adverse event which was occurred 61 (47.3%) times. Age < 1 year (AOR: 3.6, 95% CI: 1.3, 10.0), ASA ≥ 3 (AOR: 5.2, 95% CI: 1.9, 22.9), upper respiratory tract infections (AOR: 7.6, 95% CI: 1.9, 30.2), presence of secretions in the upper airway (AOR: 4.8, 95% CI: 1.4, 15.9) and airway related procedures (AOR: 6.0, 95% CI: 1.5, 24.1) were significantly associated PRAEs.
Conclusions: The incidence of PRAEs among pediatric surgical patients was relatively high (26.2%). Especially, the postoperative phase is the most critical time for the occurrence of PRAEs and desaturation was the predominant adverse event. Age less than a year, presence of upper respiratory tract infections, presence of secretions in the upper airways, ASA ≥ 3 and airway related procedures were associated with PRAEs. Clinicians should carry out effective risk assessment, optimization and adequate preparation for the management of perioperative respiratory adverse events.
This preprint is available for download as a PDF.
Table 1: Perioperative respiratory adverse events severity scoring in pediatrics patients who underwent surgery under general anesthesia.
|
Parameters |
Severity Score |
|||
|
1 (no adverse event) |
2 |
3 |
4 (serious adverse events) |
|
|
SpO2 |
95 – 100 |
90 – 94 |
80 – 89 |
< 80 |
|
Coughing (n) |
None |
1 – 2 |
3 – 4 |
Continuous |
|
Breath holding (seconds) |
None |
< 15 |
15 – 30 |
> 30 |
|
Laryngospasm |
None |
Partial obstruction requires repositioning only |
Partial obstruction requires CPAP |
Complete obstruction requires muscle relaxant |
|
Bronchospasm |
None |
Expiration phase only |
Expiration and inspiration phase |
Difficult to ventilate: treatment needed |
|
Secretions |
None |
Minimal: no suctioning |
Moderate: one suctioning |
Copious: more than one suctioning |
Table 2: Socio-demographic characteristics of pediatric surgical patients who underwent surgery under general anesthesia at UoGCSH and TGCSH, Northwest Ethiopia; March 1 – May 30, 2020 (N = 210).
|
Parameters |
Frequency n (%) |
|
Gender Female Male |
95 (45.2) 115 (54.8) |
|
Age < 1 year ≥ 1 year Median (IQR) (years) |
52 (24.8) 158 (75.2) 4.0 (1.1 – 8.0) |
IQR: Inter-quartile Range
Table 3: Clinical characteristics of pediatric surgical patients who underwent surgery under general anesthesia in UoGCSH and TGSH from March 1 – May 30, 2020 (N =210).
|
Variables |
Frequency n (%) |
Perioperative respiratory adverse events |
|
|
|
Yes n (%) |
No n (%) |
|
|
Prematurity Yes No |
14 (6.7) 196 (93.3) |
4 (28.6) 51 (26) |
10 (71.4) 145 (74) |
|
Preoperative hemoglobin < 11 g/dl ≥ 11 g/dl |
89 (42.4) 121 (57.6) |
21(23.6) 34 (28.1) |
68 (76.4) 87 (71.9) |
|
Surgical procedure ENT Ophthalmic Abdominal Orthopedic Neurosurgery |
25 (11.9) 34 (16.2) 75 (35.7) 34 (16.2) 41 (20) |
12 (48) 4 (11.8) 17 (22.7) 6 (17.6) 16 (38.1) |
13 (52) 30 (88.2) 58 (77.3) 28 (82.4) 26 (61.9) |
|
Airway device Endotracheal tube Laryngeal mask airway Facemask |
136 (64.8) 46 (21.9) 28 (13.3) |
40 (29.4) 8 (17.4) 7 (25.0) |
96 (70.6) 38 (82.6) 21 (75.0) |
|
Induction of anesthesia Intravenous Inhalation |
199 (94.8) 11 (5.2) |
51 (22.6) 4 (36.4) |
148 (74.4) 7 (63.6) |
|
Muscle relaxant Yes No |
120 (57.1) 90 (42.9) |
32 (26.7) 23 (25.6) |
88 (73.3) 67 (74.4) |
|
Time of extubation Awake extubation Deep extubation |
175 (96.2) 7 (3.8) |
46 (26.3) 2 (28.6) |
129 (73.7) 5 (71.4) |
|
Intraoperative blood loss < 100 ml 100 – 500 ml ≥ 500 ml |
72 (34.7) 99 (46.2) 41 (19.5) |
18 (25) 29 (29.9) 8 (19.5) |
54 (75) 29(29.9) 33 (80.5) |
Table 4: Pearson Chi-squared and Fisher-exact tests; factors associated with perioperative respiratory adverse events among pediatric surgical patients who underwent surgery under general anesthesia at UoGCSH and TGCSH, Northwest Ethiopia; March 1 – May 30, 2020 (N = 210)
|
Variables |
Frequency n (%) |
Desaturation n (%) |
Breath holding n (%) |
Coughing n (%) |
Airway obstruction n (%) |
Laryngospasm n (%) |
Bronchospasm n (%) |
|
|
Age
|
52 (24.8) 158 (75.2) |
22 (44.0)ᵃ 28 (56.0) |
8(50.0) 8 (50.0) |
8 (53.3)ᵇ 7 (46.7) |
5 (23.8) 16 (76.2) |
5 (41.7) 7 (58.3) |
1 (1.9) 1 (0.6) |
|
|
ASA ≥3 ≤2 |
21 (10) 189 (90) |
14 (28.0)ᵃ 36 (72.0) |
2 (12.5) 14 (87.5) |
5 (33.3) 10 (66.7) |
8 (38.1) 13 (61.9) |
2 (16.7) 10 (83.3) |
0 2 (1.1) |
|
|
URTI Yes No |
23 (11) 187 (89) |
17 (34.0)ᵃ 33 (66.0) |
4 (25.0) 12 (75.0) |
6 (40)ᵇ 9 (60) |
6 (28.5)ᵇ 15 (71.5) |
5 (41.7)ᵇ 7 (58.3) |
0 2 (1.1) |
|
|
Attempts ≥3 ≤2 |
9 (4.30) 201 (95.7) |
7 (14.0)ᵇ 38 (86.0) |
2 (12.5) 14 (87.5) |
1 (6.7) 14 (93.3) |
0 21 (100) |
3 (25)ᵇ 9 (75) |
1 (50) 1 (50) |
|
|
Secretion Yes No |
26 (12.4) 184 (87.6) |
15 (30.0)ᵃ 35 (70.0) |
5 (31.2)ᵇ 11 (68.8) |
8 (53.3)ᵇ 7 (46.7) |
9 (42.8)ᵇ 12 (57.2) |
5 (41.7)ᵇ 7 (58.3) |
0 2 (1.1) |
|
|
Procedures Airway related Non-airway related |
25 (11.9) 185 (88.1) |
10 (20)ᵃ 40 (80) |
3 (18.75) 13 (81.2) |
4 (26.6) 11 (73.4) |
7 (33.3) 14 (66.7) |
4 (33.3) 8 (66.7) |
0 2 (1.1) |
|
|
FH of Asthma Yes No |
4 (1.9) 206 (98.1) |
4 (8.0) 46 (92.0) |
0 16 (100) |
0 15 (100) |
1 (4.7) 20 (95.3) |
0 12 (100) |
2 (50.0)ᵇ 0 |
ᵃ Significant in Pearson Chi-square test
ᵇ Significant in Fisher-exact test +++++++++
Table 5: Severity of perioperative respiratory adverse events among pediatric surgical patients who underwent surgery under general anesthesia at UoGCSH and TGCSH, Northwest Ethiopia; March 1 – May 30, 2020 (N = 210).
|
Parameters |
Severity Score |
|||
|
1 n (%) |
2 n (%) |
3 n (%) |
4 n (%) |
|
|
SpO2 |
160 (76.2) |
22 (10.5) |
18 (8.6) |
10 (4.8) |
|
Coughing (n) |
194 (92.4) |
2 (1) |
14 (6.7) |
0 |
|
Breath holding (seconds) |
195 (92.9) |
9 (4.3) |
5 (2.4) |
1 (0.5) |
|
Laryngospasm |
177 (84.2) |
21 (10) |
9 (4.3) |
3 (1.4) |
|
Bronchospasm |
208 (99) |
1 (0.5) |
1 (0.5) |
0 |
|
Secretions |
184(87.6) |
0 |
15 (7.1) |
11 (5.2) |
Table 6: Bivariable and multivariable binary logistic regression analysis: factors associated with PRAEs in pediatric surgical patients who underwent surgery under general anesthesia in UoGCSH and TGCSH, Northwest Ethiopia; March 1 – May 30, 2020 (N = 210).
|
Variables |
PRAEs |
Odds ratio (95% CI) |
p-values |
||
|
Yes n (%) |
No n (%) |
Crude |
Adjusted |
|
|
|
Age < 1 year ≥ 1 year |
22 (42.3) 33 (20.9) |
30 (57.7) 125 (79.1) |
2.8 (1.4, 5.4) 1 |
3.6 (1.3, 10.0) 1 |
0.012 |
|
ASA class ≥ 3 ≤ 2 |
15 (71.4) 40 (21.2) |
6 (28.6) 149 (78.8) |
9.31 (3.4, 25.8) 1 |
5.2 (1.2, 22.9) 1 |
0.029 |
|
Urgency of the procedure Emergency Elective |
39 (34.2) 16 (16.7) |
75 (65.8) 80 (83.3) |
2.6 (1.3, 5.0) 1 |
1.41 (0.5, 3.7) 1 |
0.48 |
|
URTIs Yes No |
17 (73.9) 38 (20.3) |
6 (26.1) 149 (79.7) |
11.1 (4.1, 30.1) 1 |
7.5 (1.9, 30.2) 1 |
0.004 |
|
Surgical procedures Airway related Non-airway related |
12 (48.0) 43 (23.2) |
13 (52.0) 142 (76.8) |
3.0 (1.3, 7.2) 1 |
6.0 (1.5, 24.1) 1 |
0.012 |
|
Secretions in the upper airway Moderate to copious None to minimal |
18 (69.2) 37 (20.1) |
8 (30.8) 147 (79.9) |
8.9 (3.6, 22.2) 1 |
4.78 (1.4, 18.8) 1 |
0.011 |
|
Light anesthesia Yes No |
10 (41.7) 45 (24.2) |
14 (58.3) 141 (75.8) |
2.2 (0.9, 5.4) 1 |
2.6 (0.7, 9.8) 1 |
0.14 |
|
Intubation attempts ≥ 3 ≤ 2 |
7 (77.8) 42 (24.1) |
2 (22.2) 132 (75.9) |
11 (2.2, 55.0) 1 |
3.9 (0.5, 28.0) 1 |
0.17 |
|
Duration of surgery (hour) ≥ 1 < 1 |
39 (37.7) 16 (18.4) |
84 (68.3) 71 (81.6) |
2 (1.1, 4.0) 1 |
2.0 (0.7, 5.9) 1 |
0.19 |