Postoperative Outcome in Non-Preterm Infants Under One Year Old in Non-Cardiac Surgery

Claudine Kumba*

Department of Pediatric and Obstetric Anesthesia and Critical Care, Hôpital Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, APHP, Université de Paris, Paris, France

*Corresponding Author: Claudine Kumba, Department of Pediatric and Obstetric Anesthesia and Critical Care, Hôpital Universitaire Necker Enfants Malades, Assistance Publique Hôpitaux de Paris, APHP, Université de Paris, Paris, France.

Received: May 10, 2021; Published: July 05, 2021

Citation: Claudine Kumba. “Postoperative Outcome in Non-Preterm Infants Under One Year Old in Non-Cardiac Surgery”. Acta Scientific Paediatrics 4.8 (2021): 11-23.

Abstract

Background: An observational study conducted earlier to determine predictors of postoperative outcome in non-cardiac surgical pediatric patients showed that factors which influenced postoperative evolution were multiple. These included American Society of Anesthesiologists (ASA) score, transfusion, age, emergency surgery, and surgery.

Objectives: To describe in details outcomes in non-preterm children under one year old included in the initial study.

Methods: Secondary analysis of the initial retrospective observational study in 594 patients with a mean age of 90.86 ± 71.80 months.

The Ethics Committee approved the study under the registration number 2017-CK-5-R1.

Results: There were 97 non-preterm children included with a mean age of 4.44 ± 3.49 months.

Mean weight was 5.13 ± 2.74 kilograms. There were 48 abdominal surgical patients (49.49%), 48 neurosurgical patients (49.49%) and 1 orthopedic surgery patient (1.03%). 30 patients had intra-operative and or postoperative complications (organ failure or sepsis) (30.93%). The most common intra-operative complication was hemorrhagic shock (5.16%); the most affected system in the postoperative period was the respiratory system in terms of organ failure and pulmonary sepsis with an overall rate of 12.38%; the most common postoperative infection was septicemia (7.22%). The rate of postoperative renal failure was 1.03%. There were 5 inhospital deaths (5.16%) and all were ASA III, IV and V patients managed on an emergency basis.

Conclusion: In this cohort of 97 non-preterm infants under one year old, the rate of patients with intra-operative and or postoperative complications was 30.93%. Patients with fatal outcome had an ASA score III or more and were managed on an emergency basis.

It is time to reconsider integrating goal directed therapies in intra-operative patient management to improve postoperative outcome.

Keywords: Children Under One Year Old; Outcome; Non-Cardiac Surgery

Introduction

An observational study conducted earlier to determine predictors of postoperative outcome in non-cardiac surgical pediatric patients concluded that predictors of postoperative evolution were multiple [1]. These included American Society of Anesthesiologists (ASA) status, transfusion, age, emergency surgery and surgery. Postoperative outcome in this observational trial was defined as intra-operative and postoperative complications (organ failure and sepsis), re-surgery, mortality, length of stay in the intensive care unit (LOSICU), length of stay in hospital (LOS), total length of stay in hospital, TLOS (LOSICU+LOS) and length of mechanical ventilation (LMV).

Objective of the Study

The study presented in this article had the objective to describe these outcomes in children under one year old in details.

Methods

Description of intra-operative and postoperative outcomes in children less than one year old included in the initial cohort of 594 patients aged 90.86 ± 71.80 months [1].

The study was declared to the CNIL, National Commission for Computer Science and Liberties on 21 February 2017 under the registration number 2028257 v0. The Ethics Committee of Necker approved the study on 21 March 2017 under the registration number 2017-CK-5-R1. Patients were included retrospectively from 1 January 2014 to 17 May 2017.

Inclusion criteria were children aged less than one year and older than 37 weeks.

Exclusion criteria were children aged less than 37 weeks and older than one year.

Statistics were analyzed with XLSTAT 2020.4.1. software.

Continuous variables were described in means ± standard deviation or medians with interquartile ranges. Categorial variables were described in proportions. Categoric variables were compared with Fischer’s exact test. A p-value of less than 0.05 was considered significant.

Results

General characteristics are illustrated in table 1.

There were 97 children included with a mean age of 4.44 ± 3.49 months. Mean weight was 5.13 ± 2.74 kilograms. There were 48 abdominal surgical patients (49.49%), 48 neurosurgical patients (49.49%) and 1 orthopedic surgical patient (1.03%). 57 patients had elective surgery (58.76%) and 40 had emergency surgery (41.24%). 11 patients had re-surgery (11.34%). 30 patients had in tra-operative and or postoperative complications (organ failure or sepsis) (30.93%). 5 patients had intra-operative hemorrhagic shock (5.16%), 1 patient had an intra-operative cardiac arrest (1.03%) and 1 patient had an intra-operative bronchospasm/laryngospasm (1.03%). 2 patients had postoperative neurologic failure (2.06%), 5 patients had postoperative cardio-circulatory failure (5.16%), 6 patients had postoperative respiratory failure (6.19%), 1 patient had postoperative renal failure (1.03%), 5 patients had postoperative multi-organ failure (5.15%), and 1 patient had postoperative hemorrhagic shock (1.03%). 6 patients had postoperative pulmonary sepsis (6.19%), 6 patients had postoperative abdominal sepsis (6.19%), 2 patients had postoperative neuro-meningeal sepsis (2.6%), 7 patients had postoperative septicemia (7.22%) and 1 patient had postoperative multi-organ sepsis (1.03%). 67 patients received transfusion intra-operatively (69.07%). There were 5 inhospital deaths (5.16%) and all were ASA III or more and were managed on an emergency basis. Among the deceased patients 1 had a liver transplantation, 1 had an intestinal resection, 1 had a laparotomy for volvulus, 1 had a cerebral aneurysm embolization and 1 had an extradural hematoma drainage (See table 2).

There were 31 ASA I (31.96%), 23 ASA II (23.71%), 26 ASA III (26.80%), 15 ASA IV (15.46%) and 2 ASA V patients (2.06%) (Table 3).

Median length of postoperative intensive care unit stay (LOSICU) was 4 days [3 - 16], median length of postoperative hospital stay (LOS) was 4 days [1 - 18], median total length of postoperative hospital stay, TLOS (LOSICU+LOS) was 12 days [4 - 34] and median length of postoperative mechanical invasive or non-invasive mechanical ventilation (LMV) was 0 days [0 - 3].

The majority of the patients (69.07%) were transfused intraoperatively.

Mean preoperative hemoglobin levels were 12.07 ± 3.09 g/dL and mean postoperative hemoglobin levels were 12.40 ± 2.54 g/ dL.

Table 3 illustrates types of surgery, the most common surgical intervention was craniosynostosis (39 patients; 40%), followed by intestinal resection (11 patients; 11%), hepatic transplantation (7 patients;7%), esophageal atresia (5 patients; 5%), omphalocele (5 patients; 5%) and laparotomy for volvulus (4 patients, 4%).

Table 4 illustrates outcomes per surgery and table 5 illustrates p-values for complications per surgery.

Discussion

The most common intra-operative complication was hemorrhagic shock (5.16%), followed by broncho-laryngo spasm (1.03%) and cardiac arrest (1.03%). Among the most common interventions described in this manuscript, craniosynostosis and liver transplantation were among the most hemorrhagic interventions this explains the rate of intra-operative hemorrhagic shock. Transfusion rate was 69.07% in this study. A previous study in craniosynostosis has reported a transfusion rate of 100% which was reduced to 22.7% after an implementation program with aim to reduce transfusion [2] and another study reported a transfusion rate of 66% [3]. A study in liver transplantation in children revealed a massive transfusion rate of 55% [4].

The rate of intra-operative cardiac arrest was higher than that reported in a study of infants aged less than 60 weeks of postmenstrual age which showed a rate of 0.12% [5]. Nevertheless, this same study revealed that intra-operative critical events were present in 35.3% of the patients and the most common concerned the cardiovascular instability and hypoxemia [5]. In our study the rate of intra-operative critical events was 7.22% which included hemorrhagic shock, broncho-laryngospasm and cardiac arrest. The Nectarine study reported an intra-operative serious event rate of 35.3% and a 30 days morbidity rate of 16.3% with respiratory, surgical and cardiovascular complications as common events keeping in mind that this study included pre-terms and term patients up-to 60 weeks postmenstrual age [5]. Our study included term infants and pre-terms were not included.

In our study the rate of patients with intra-operative and or postoperative complications was 30.93%. The respiratory system was the most affected in the postoperative period with overall complication rate of 12.38% which included respiratory failure (6.19%) and pulmonary sepsis (6.19%). According to 2 previous studies, postoperative pneumonia rate varied between < 1% to 1.2% [3,6,7]. Re-surgery was present in 11.34% of the patients in our study. Previous studies have reported a re-operation rate between 2 and 5% [3,8]. Postoperative cardio-circulatory failure (5.16%) and multi-organ failure (5.16%) were the second most frequent postoperative systemic failures followed by neurologic dysfunction which included neurologic failure (2.06%) and neuromeningeal sepsis (2.06%). According to a previous narrative review, the incidence multiple organ dysfunction in pediatric intensive care unit (PICU) varies from 6 to 57% according to the studies [9]. Mortality rates from multi-organ dysfunction varies from < 5% to > 80% depending on the number of organ failure [9]. The most common cause of multi-organ failure is sepsis with an overall rate of 17 to 73% [9].

The most common postoperative infection in our study was septicemia (7.22%), followed by pulmonary (6.19%) and abdominal sepsis (6.19%). Postoperative septicemia rates has been reported to vary from 25 to 33% in liver transplantation surgery [7,10]. One study in liver transplantation, reported a postoperative abdominal sepsis of 25% [10]. In a study in infants aged less than 6 months overall postoperative sepsis was 6.9% [11]. In this study same, factors related to postoperative sepsis were laparotomy, thoracotomy, diaphragmatic repair, low age and a long intervention time. Independent predictors of postoperative sepsis were central venous catheter and perioperative antibiotics [11].

In-hospital mortality rate was 5.16% in our study. All patients had a ASA score of more than 3, were managed on an emergency basis. All the deceased patients had postoperative multi-organ failure and sepsis, all were aged less than 10 months and had co-morbidities. In the literature, mortality rates vary form 0% in surgery like craniosynostosis to high rates of 17.7% in liver transplantation, of 19.6% in ruptured cerebral aneurysms and more than 80% in patients with multi-organ failure with sepsis [2-6,8-10,12-22].

This study has shown that in children under one year old in major hemorrhagic non cardiac surgery, hemorrhagic shock was the most common intra-operative complication. In our Hospital we do not have transfusion protocols guided with point of care tests [23]. It is time to consider the integration of these protocols in major hemorrhagic surgery to reduce transfusion and improve outcome [23].

One third of patients in this cohort presented intra-operative and or postoperative complications and patients with fatal outcome were all ASA 3 or more. It is time to reconsider the integration of fluid and hemodynamic goal directed therapy in these patients with the aim to improve postoperative evolution since these protocols are not yet a routine practice in our Hospital [24-31].

Postoperative outcome is multifactorial, intra-operative management plays a major role on postoperative evolution. Intra-operative fluid and hemodynamic optimization is one of the keys to upgrade postoperative outcome.

Conclusion

This secondary analysis of 97 non pre-term infants aged less than one year old, revealed that hemorrhagic shock was the most common intra-operative complication, in the postoperative period, the respiratory system was the most affected system, septicemia was the most common postoperative infection and in-hospital mortality rate was 5.16%. Patients with fatal outcome had ASA scores of 3 or more with severe co-morbidities.

It is time to reconsider integrating goal directed therapies in intraoperative patient management to improve postoperative outcome.

Conflicts of Interest

The author declared no conflicts of interest.

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Copyright: © 2021 Claudine Kumba. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.