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                                                                                                                                                                                                                                              The analysis of pediatric closed malpractice claims regularly describes the causal relationship between anesthetic practice and morbidity as well mortality in previously healthy children. (1) Partial brain damage, persistent vegetative state, brain death or even death represent only the most catastrophic outcomes. Unfortunately, these outcomes merely represent the 'tip of the iceberg' as they do not include incidences and 'near misses', which do not result in lawsuits. Subclinical cerebral damage caused by perioperative adverse events including perioperative cardiac arrest (POCA), prolonged cardio-respiratory depression or brain swelling due to free water administration in children undergoing anesthesia are frequently a result of a poor conduct of anesthesia. This is not always disclosed to parents, investigated or reported. (2) Complications in pediatric anesthesia are directly related to the (in-) experience of the anesthesiologist in charge. Occasional pediatric anesthetic practice (less than 100 per annum per anesthesiologist) carries a 5 times increased risk for complications when compared to regular operators (more than 200 p.a.). (3)

Cerebral Hypoperfusion

Hypotension and/or hypocapnia lead to cerebral hypoperfusion and brain injury. (4, 20) However, hypotension in neonates and small children during anesthesia is frequently tolerated and even accepted. Treatment threshold for neonatal systolic hypotension are significantly different, e.g. between North America at 45.5 mmHg and the internationally recommended 60 mmHg, respectively. (5,6) Whether this difference alone explains the discrepancies in reported retrospective outcome studies is speculative. (7-12) (20)


Younger and smaller children are at high risk of perioperative hypoxemia due to the relatively higher oxygen demand and lower oxygen reserves. Prolonged hypoxic episodes frequently occur in the perioperative period and are common at induction of anesthesia for emergency procedures. (13- 15)


The impact of the traditional and now largely abandoned perioperative use of hypotonic fluids on perioperative cerebral damage is not considered in retrospective human outcome studies. Profound hyponatremia results in seizure activity, coma and death. Only the most severe cases and series are reported. (16-19) Moderate perioperative hyponatremia can be suspected to cause subclinical neuronal damage detectable only years after surgery with sophisticated neurocognitive testing.
Safetots.org initiative illustrates the known perioperative causes for cerebral morbidity in young children.
1. Jimenez N, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. An update on pediatric anesthesia liability: a closed claims analysis.     Anesth Analg. 2007; 104: 147-53. 2. Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, Campos JS, Morray JP. Anesthesia-related cardiac arrest     in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. 2007; 105: 344-50. 3. Auroy Y, Ecoffey C, Messiah A, Rouvier B. Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics.     Anesth Analg. 1997; 84: 234-5. 4. McCann ME, Schouten AN. Beyond survival; influences of blood pressure, cerebral perfusion and anesthesia on neurodevelopment.     Paediatr Anaesth. 2014; 24: 68-73. 5. Nafiu OO, Voepel-Lewis T, Morris M, Chimbira WT, Malviya S, Reynolds Pl, Tremper KK. How do pediatric anesthesiologists define intraoperative     hypotension? Paediatr Anaesth. 2009; 19: 1048-53. 6. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 10: pediatric advanced life support. The American Heart     Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000; 102: I291–I342. 7. Sinner B, Becke K, Engelhard K. [Neurotoxicity of general anesthetics in childhood. Does anesthesia leave its mark on premature babies, newborns     and infants?]. Anaesthesists 2013; 62: 91-100. 8. DiMaggio C, Sun LS, Kakavouli A, Byrne MW, Li G. A retrospective cohort study of the association of anesthesia and hernia repair surgery with     behavioral and developmental disorders in young children. J Neurosurg Anesthesiol. 2009; 21: 286- 91. 9. Wilder RT, Flick RP, Sprung J, Katusic SK, Barbaresi WJ, Mickelson C, Gleich SJ, Schroeder DR, Weaver AL, Warner DO. Early exposure to     anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology. 2009; 110:796-804. 10. Bartels M, Althoff RR, Boomsma DI. Anesthesia and cognitive performance in children: no evidence for a causal relationship.      Twin Res Hum Genet. 2009; 12: 246- 53. 11. Hansen TG, Pedersen JK, Henneberg SW, Pedersen DA, Murray JC, Morton NS, Christensen K. Academic performance in adolescence after      inguinal hernia repair in infancy: a nationwide cohort study. Anesthesiology. 2011; 114: 1076-85. 12. Hansen TG, Pedersen JK, Henneberg SW, Morton NS, Christensen K. Educational outcome in adolescence following pyloric stenosis repair       before 3 months of age: a nationwide cohort study. Paediatr Anaesth. 2013; 23: 883-90. 13. deGraaff JC, Bijker JB, Kappen TH, van Wolfswinkel L, Zuithoff NP, Kalkman CJ. Incidence of intraoperative hypoxemia in children in relation to age.      Anesth Analg. 2013; 117: 169-75. 14. Gencorelli, Encorelli FJ, Fields RG, Litman RS. Complications during rapid sequence induction of general anesthesia in children: a benchmark study.      Paediatr Anaesth. 2010; 20: 421-4. 15. Görges M, West N, Cassidy M, Ansermino JM, Lauder G. Vital signs changes in neonates during general anesthesia: a retrospective data review.       APA ASM 2014; 16. Sümpelmann R, Becke K, Crean P, Jöhr M,Lönnquist PA,Strauss JM, Veyckemans F; German Scientific Working Group for pediatric Anaesthesia.       European consensus statement for intraoperative fluid therapy in children. Eur J Anaesthesiol. 2011; 28: 637-9. 17. Arieff AI. Hyponatremia, convulsions, respiratory arrest, and permanent brain damage after elective surgery in healthy women.      N Engl J Med.1986; 314: 1529-35. 18. Arieff AI, Ayus, JC, Fraser CL. Hyponatremia and death or permanent brain damage in healthy children. BMJ. 1992; 304: 1218-22. 19. Paut O, Remond C, Lagier P, Fortier G, Camboulives J. [Severe hyponatremic encephalopathy after pediatric surgery: report of seven cases and      recommendations for management and prevention]. Ann Fr Anesth Reanim.2000; 19: 467-73. 20. Görges M, West NC, Karlsdottir E, Ansermino JM, Cassidy M, Lauder GR. Developing an objective method for analyzing vital signs changes in      neonates during general anesthesia. Paediatr Anaest. 2016 Aug 24  [Epub ahaed of print].