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Catastrophic and Critical Intraoperative Events during Pediatric Craniofacial Surgery
Diana Kennedy1, Christine B Novak1, John H Phillips1
1Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Catastrophic events during pediatric craniofacial surgery are rare, with a 0.67% incidence in this study. Experienced teams successfully managed critical intraoperative events, resulting in no patient mortalities.
Area of Science:
- Pediatric Surgery
- Craniofacial Surgery
- Patient Safety
Background:
- Pediatric craniofacial surgery in tertiary centers is generally safe with low mortality.
- Complex cases can still lead to catastrophic and life-threatening intraoperative events.
- This study investigates the incidence and outcomes of such critical events.
Purpose of the Study:
- To determine the incidence of catastrophic and critical intraoperative events during pediatric craniofacial surgery.
- To analyze the acute outcomes of these events.
- To evaluate the effectiveness of management strategies in a high-volume center.
Main Methods:
- Review of 7214 procedures performed by two senior surgeons over 18 years (2002-2019).
- Identification of catastrophic or critical intraoperative events requiring emergency code activation.
- Analysis of operative details and acute outcomes for 14 identified events.
Main Results:
- A total of 14 critical events (0.67% incidence) occurred in 7214 procedures.
- Events included venous air embolism, cardiac complications, major hemorrhage, and trigeminocardiac reflex.
- No mortalities were recorded; surgery was curtailed in 7 cases and completed in 7.
Conclusions:
- Catastrophic, life-threatening events in pediatric craniofacial surgery are infrequent.
- Experienced surgical and anesthesia teams effectively managed critical intraoperative events, preventing mortality.
- This highlights the importance of specialized teams in high-volume pediatric craniofacial centers.
Abstract:
Pediatric craniofacial surgery performed in tertiary care centers by dedicated teams is associated with high levels of safety and low rates of mortality. However, catastrophic and life-threatening events may occur as a result of surgical management of these complex patients. This study reviewed the incidence and acute outcomes of catastrophic and critical events during craniofacial surgery at a single high-volume center.
Methods:
The data reviewed included the operative procedures of two senior craniofacial surgeons over an 18-year period at a tertiary care pediatric craniofacial center. Catastrophic or critical intraoperative events were defined as events requiring the activation of an emergency code during surgery. The operative details and acute outcomes were reviewed and analyzed.
Results:
This study reviewed 7214 procedures performed between January 2002 and January 2019. There were 2072 (29%) cases classified as major craniofacial procedures (transcranial, mixed trans-and-extracranial, or major extracranial facial osteotomies), and code events occurred in 14 cases (0.67%; one in 148 patients): venous air embolism (n = 4), cardiac complications (n = 3), major hemorrhage (n = 3), trigeminocardiac reflex (n = 2), acute intracranial hypertension (n = 1), and acute airway obstruction (n = 1). Two cases (14%) experienced a critical event that was anesthesia-related. Cardiac arrest requiring compressions and/or defibrillation was necessary for eight patients. There were no mortalities. Surgery was curtailed in seven cases and successfully completed in seven patients.
Conclusions:
Catastrophic life-threatening events during pediatric craniofacial surgery are, fortunately, rare. In our institution, experienced teams in the management of catastrophic and critical intraoperative events during major pediatric craniofacial procedures resulted in no mortalities.
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