© www.SAFETOTS.org 2015


Unfortunately, there is no widespread and supported research activity on caseload and experience of anesthesiologists and related complications. Research activity on ‘safe conduct’ of anesthesia is similarly sporadic and not coordinated. A recently reported case series indicates that the conduct of anesthesia directly influences morbidity in vulnerable brains. (1) Several reviewers and expert witnesses are in a position to add numerous similar cases but they are difficult or impossible to access. The European Society of Anesthesiology sponsored APRICOT project (www.esahq.org/apricot) will probably provide further information regarding the relationship between caseload, organizational setup and outcome in pediatric anesthesia. Current pediatric anesthesia research is concentrating on the effects of neurotoxicity (GABAA, NMDA receptors and apoptosis) instead on safe conduct of general anesthesia (blood pressures, PaCO2, electrolytes, temperature and blood glucose) in the vulnerable child. However, is this current research the best we can offer these children or is this merely an academically lucrative one? Unfortunately, evidence-based improvement of pediatric anesthesia is hampered by a lack of financial incentive (grants), recognition (impact factors), and lack of personal gain (professional advancement). Research on ‘anesthetic agent-related neuro-morbidity’ rather than evaluation of the impact of good clinical practice as well as dedicated teaching and supervision of residents is currently perceived academically more rewarding. Assurance of quality clinical care requires relentless vigilance and a sustained commitment to proper training, education and supervision in pediatric anesthesia. This requires maintenance of knowledge and focused clinical expertise in the care of infants and children. It is our strong conviction that failure to do so will diminish our role in mitigating perioperative morbidity in this vulnerable age group.

Anesthesiologist's related cerebral damage in children

is ignored

A huge amount of money (public donations and grants) is currently invested into animal and clinical research investigating the neurotoxic effects of anesthetic agents on the neuro-developmental outcome in vulnerable brains. However, there is as yet only little if any money at all available to investigate the effects of anesthesiologists competence on complications and neurological outcome in small children undergoing anesthesia. In addition to the lesser academic attractiveness it raises the question if it is easier, cheaper and more beneficial for governing bodies to fund research on neurotoxicity rather than investing money in standardising skills, experience and environment/setting for pediatric anesthesia? Is it easier to explain and distract that anesthetic agents are responsible for 'adverse neurological outcomes’ in children following surgery, rather than to admit, that there are not sufficient resources available or directed respectively for adequate perioperative anesthesia care for each child? Although it is now common knowledge that children in inexperienced hands have a higher perioperative anesthetic morbidity several national anesthesia societies are not willing to accept and pursue a certification of specialized pediatric anesthesia as recently developed by the American Board of Anesthesiology (www.theaba.org/Home/examinations_certifications). The concept that a general anesthesiologist is able to provide anesthetic care for all patients from birth to any old age is outdated. In Denmark, anesthesia in children younger than 2 years of age is no longer part of the anesthesiological curriculum. These are all uncomfortable points and speculative questions, which, however, have to be addressed.

Future research

Future research on cognitive deficits and learning disabilities following general anesthesia in early childhood must investigate the impact of perioperative hypotension, hypocarbia, hypoxemia, hyponatremia, hypo- and hyperglycemia on brain injury and neurodevelopment. The open and unanswered questions of 'What is normal?', 'What is the minimal safe blood pressure?', 'What are the effects of anesthetics on the lower limit of cerebral autoregulation ?' and 'How is cerebral perfusion during anesthesia safely monitored?' must be investigated and answered. The questions are a widely known and are a major serious concern that surely must be an automatic trigger to invest precious financial and personal resources. Future prospective clinical studies investigating potential neurotoxic effects of anesthetic agents on the vulnerable brain have to outline and report peri-operative anesthetic care data (cf. 10-N-Quality Pediatric Anesthesia). Vital sign data should to be recorded by electronic patient data management systems (PDMS) as written anesthesia charts are not always completed in a timely fashion. Adverse events are often incorrectly noted retrospectively or not at all. Similarly, in multicentre studies, no one single centre likes to be identified to be an ‘outlier’ and report a high rate of complications and perioperative adverse events. Therefore, on-going prospective clinical studies without documented vital sign parameter by the means of a PDMS (Patient Data Management System) have to be interpreted with care!                                                                                                                                                                              
Safetots.org initiative addresses important issues for further clinical prospective anesthesia outcome research in young children.
References 1.  McCann ME, Schouten AN, Dobija N, Munoz C, Stephenson L, Poussaint T, Kalkman C, Hickey PR. de Vries L, Tasker R. Infantile postoperative      encephalopathy: perioperative  factors as a cause for concern. Pediatrics. 2014; 133: e751-7.