Perioperative Complications in Multispecialty Surgical Care for Patients With Trisomy 21
A Single Center Retrospective Cohort Study.
Paediatric anaesthesia
Submitted June 2026 by Dr Nicole Wong
Review summary
This retrospective cohort study evaluated the association of multispecialty surgical care and perioperative risk in paediatric patients with Trisomy 21.
The multisystem comorbidities of Trisomy 21 patients commonly necessitate frequent surgical, interventional and imaging procedures requiring general anaesthesia. As a result, there is potential for a higher frequency of perioperative safety events in children with Trisomy 21 compared to their age-matched peers.
In this study, multispecialty surgical care refers to performing two or more procedures from different subspecialties under the same anaesthetic. This is a proposed method to minimise perioperative risk by avoiding repeated inductions, airway manipulations and recovery from anaesthesia, as well as reducing the frequency of healthcare visits and the emotional burden on children and their families.
Patient demographic information, procedural data and perioperative safety events were retrospectively extracted from all anaesthesia cases performed at Children’s Wisconsin over 9.6 years. Perioperative safety events were defined as either an intraoperative event (from anaesthesia start to PACU discharge) or a postoperative event (within 48 hours from PACU discharge) occurring within a single case. Severity of these safety events were classified based on the extent of care escalation required.
Key findings
This cohort included 219,626 anaesthesia cases performed in 120,299 patients. Of this, 3,873 anaesthesia cases were performed in 995 patients with Trisomy 21.
The Trisomy 21 cohort were of lower age and weight, higher ASA, and had longer anaesthesia duration compared to the rest of the anaesthesia population.
Compared to the total study population, the Trisomy 21 cohort and had a higher likelihood of:
- multiple anaesthetics per patient (OR = 8.02 [95% CI 7.11-9.04])
- multispecialty care (OR = 3.95 [95% CI 3.6-4.3])
- perioperative safety events (OR = 5.65 [95% CI 4.51-7.08])
Independent risk factors associated with perioperative safety events within the Trisomy 21 population included:
- ASA > 3
- African American ethnicity
- anaesthesia duration (> 240 mins)
- multispecialty case
The number of anaesthetics per patient was not associated with an increased risk of safety events – it was identified as a protective factor instead.
Commentary
This study provides an insight into some of the risk factors affecting perioperative safety events and evaluates the risks of multispecialty surgical care for children with Trisomy 21. Its strengths include the large study population and the use of validated scoring tools to classify and quantify the severity of perioperative safety events.
This study has some limitations that can affect the generalisability and applicability of key findings reported.
The single-centre, retrospective design, and the exclusion of trauma surgeries from multispecialty case analysis may introduce selection bias. Additionally, the lack of categorisation of the reported perioperative safety events and the limited description of the surgical subspecialties involved in multispecialty cases may restrict the study’s insights. Although this study analysed a large sample size, the data was collected over a prolonged period (9.6 years), during which perioperative safety practices and guidelines may have evolved, potentially acting as a confounding factor. Furthermore, a large proportion of safety events were retrospectively self-reported by clinicians, which may have led to recall bias.
Given the retrospective design of this study, a definitive causal relationship between the identified risk factors and safety events cannot be established. Anaesthetic duration and multispecialty cases were identified as significant risk factors; however, the underlying reasons influencing anaesthetic duration and the factors associated with multispecialty surgical care were not conducted. Consequently, additional risk factors, such as clinician seniority or time of day surgery occurred, may not have been captured in this analysis.
Although the authors alluded to the potential benefits of multispecialty surgical practice – such as decreasing healthcare costs, improved time efficiency, and decreased emotional burden on families – the economic impact or perceived benefits by families were not evaluated.
Take home messages
Multispecialty surgical care is often opportunistically utilised within institutions to reduce anaesthetic exposure, ease scheduling pressures, and lessen the emotional burden on children and their families. However, this study demonstrated that multispecialty surgical care may increase the risk of perioperative safety events, whilst a greater number of anasesthetic exposures per patient was identified as a protective factor instead. Consequently, careful scheduling practices are warranted, such as considering separate single specialty cases or limiting the duration of multispecialty scheduling to less than four hours.
In our institution planned combined procedures are typically limited to diagnostic pairings (e.g. MRI and lumbar puncture), procedures with linked or associated pathologies (e.g. cleft palate repair and myringotomy tube insertion), or trauma-related cases. In our setting, multispecialty surgical procedures are not limited to children with Trisomy 21, but are also utilised for children with other chronic, multisystem conditions (e.g. cerebral palsy), or those with significant behavioural concerns where repeated perioperative management may be challenging.
Whilst multispecialty care may offer perceived benefits, it is important to consider institutional factors, including proceduralist availability, access to appropriate theatre environments, and equipment constraints (e.g. MRI availability). Overall, this paper provides a valuable foundation for future research to further evaluate the risk-benefit balance of multispecialty surgical care in the peadiatric population to help inform clinicians and families about competing interests and how best to deliver such care safely if necessary or preferred.
