Evaluation of quality of care in neonatal anesthesia using a bundle of intraoperative parameters
Submitted December 2023 by Dr Eamonn Upperton
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Inspired by the SAFETOTS ‘10Ns’ of quality in paediatric anaesthesia, this paper sets out to measure how often physiological variables stray outside the target range during and after neonatal surgery.
The authors retrospectively analysed parameters from 53 gastroschisis repairs, reporting whether each was kept within a pre-defined range for a specified percentage of the case. The parameters examined were:
• Mean arterial pressure
• Heart rate
• End-tidal CO2
• Blood glucose
• Serum sodium
The primary outcome of the study was to determine how many of these parameters were measured in each case. These were well monitored, with a median 6 of 7 variables measured (range 4-7).
The secondary outcomes analysed the frequency with which these parameters were kept within a retrospectively applied target range. Of these, only oxygen saturation and heart rate were kept within range in more than 80% of cases.
The findings in this paper demonstrate some of the challenges inherent to developing indicators of quality in anaesthesia; namely, that measured parameters are often a surrogate for the actual variable of interest. Here, 72% of the neonates undergoing anaesthesia experienced blood pressure measurements below the target for greater than 25% of the duration of the case; whether this translates to low end-organ perfusion is not clear.
As a less frequently measured variable, the inclusion of “normal serum sodium” in SAFETOTS is in part a recognition of the risks posed by “4% and a fifth” hypotonic crystalloid solutions. The authors of this paper sensibly recommend that using a balanced crystalloid solution in routine surgery may preclude the need for sodium monitoring.
The anaesthetic technique described here has some notable differences to local practice, which may have influenced the physiological variables to some degree. For example, in most cases (86%) anaesthesia was induced in NICU by the neonatologist before transfer to the operating theatre. Even with these variations in technique, the difficulty we face in meeting parameter targets for these patients is evidently universal.
This paper highlights the challenges of translating imperfect physiological measurements to markers of quality. Despite the difficulty of consistently achieving these physiological aims, it may well be that the pursuit of target parameters is more important than the absolute numbers themselves.