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Hypoxemia in School-age Children Undergoing One-lung Ventilation: A Retrospective Cohort Study from the Multicenter
T Wesley Templeton1, Bridget Krol2, Scott Miller1
1Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Insights
Hypoxemia risk in children undergoing one-lung ventilation is linked to initial oxygen saturation below 98%. Factors like extremes of weight and right-sided surgery increase risk in older children.
Area of Science:
- Pediatric Anesthesiology
- Thoracic Surgery
- Respiratory Physiology
Background:
- Hypoxemia during one-lung ventilation (OLV) in children is not well understood.
- Identifying risk factors is crucial for improving patient outcomes.
- This study investigates modifiable and nonmodifiable factors associated with hypoxemia in pediatric OLV.
Purpose of the Study:
- To identify risk factors for hypoxemia in school-age children (4-17 years) undergoing thoracic surgery with OLV.
- To differentiate risk factors between younger (4-9 years) and older (10-17 years) pediatric cohorts.
Main Methods:
- Retrospective analysis of the Multicenter Perioperative Outcomes Group database.
- Inclusion of children aged 4-17 undergoing OLV, excluding cardiac/vascular procedures.
- Definition of hypoxemia (SpO2 < 90% for ≥3 min) and severe hypoxemia (SpO2 < 90% for ≥5 min).
- Multivariable regression analysis to evaluate risk factors including age, weight, ASA status, OLV duration, initial SpO2, surgical approach, and ventilation strategy.
Main Results:
- Hypoxemia prevalence was 10.5% in 4-9 year olds and 7.5% in 10-17 year olds.
- Severe hypoxemia prevalence was 6.1% and 4.6% in the respective age groups.
- Initial SpO2 < 98% was a significant risk factor for hypoxemia in both age groups.
- Extremes of weight, right-sided surgery, and younger age (in the older cohort) were associated with increased hypoxemia risk.
Conclusions:
- An initial room air oxygen saturation below 98% is a key risk factor for hypoxemia in children undergoing OLV.
- Extremes of weight, right-sided procedures, and younger age (within the older cohort) are significant risk factors for hypoxemia.
- These findings aid in risk stratification and management strategies for pediatric thoracic surgery patients.
Background:
Risk factors for hypoxemia in school-age children undergoing one-lung ventilation remain poorly understood. The hypothesis was that certain modifiable and nonmodifiable factors may be associated with increased risk of hypoxemia in school-age children undergoing one-lung ventilation and thoracic surgery.
Methods:
The Multicenter Perioperative Outcomes Group database was queried for children 4 to 17 yr of age undergoing one-lung ventilation. Patients undergoing vascular or cardiac procedures were excluded. The original cohort was divided into two cohorts: 4 to 9 and 10 to 17 yr of age inclusive. All records were reviewed electronically for the primary outcome of hypoxemia during one-lung ventilation, which was defined as an oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or longer continuously, while severe hypoxemia was defined as Spo2 less than 90% for 5 min or longer. Potential modifiable and nonmodifiable risk factors associated with these outcomes were evaluated using separate multivariable least absolute shrinkage and selection operator regression analyses for each cohort. The covariates evaluated included age, extremes of weight, American Society of Anesthesiologists Physical Status of III or higher, duration of one-lung ventilation, preoperative Spo2 less than 98%, approach to one-lung ventilation, right operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (defined as tidal volume of 6 ml/kg or less and positive end-expiratory pressure of 4 cm H2O or greater for more than 80% of the duration of one-lung ventilation), and procedure type.
Results:
The prevalence of hypoxemia in the 4- to 9-yr-old cohort and the 10- to 17-yr-old cohort was 24 of 228 (10.5% [95% CI, 6.5 to 14.5%]) and 76 of 1,012 (7.5% [95% CI, 5.9 to 9.1%]), respectively. The prevalence of severe hypoxemia in both cohorts was 14 of 228 (6.1% [95% CI, 3.0 to 9.3%]) and 47 of 1,012 (4.6% [95% CI, 3.3 to 5.8%]). Initial Spo2 less than 98% was associated with hypoxemia in the 4- to 9-yr-old cohort (odds ratio, 4.20 [95% CI, 1.61 to 6.29]). Initial Spo2 less than 98% (odds ratio, 2.76 [95% CI, 1.69 to 4.48]), extremes of weight (odds ratio, 2.18 [95% CI, 1.29 to 3.61]), and right-sided cases (odds ratio, 2.33 [95% CI, 1.41 to 3.92]) were associated with an increased risk of hypoxemia in the older cohort. Increasing age (1-yr increment; odds ratio, 0.88 [95% CI, 0.80 to 0.97]) was associated with a decreased risk of hypoxemia.
Conclusions:
An initial room air oxygen saturation of less than 98% was associated with an increased risk of hypoxemia in all children 4 to 17 yr of age. Extremes of weight, right-sided cases, and decreasing age were associated with an increased risk of hypoxemia in children 10 to 17 yr of age.
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