Analysis of anesthesia related severe adverse events in congenital catheterization cases from a single institution

Anesthetic management of patients undergoing congenital cardiac catheterization is challenging due to complexity and variability of patient characteristics and wide ranging interventional and diagnostic procedures. The Congenital Cardiac Catheterization Project on Outcomes (C3PO) Registry was created in 2007 to record patient characteristics and outcomes in congenital cardiac catheterization procedures and currently has 18 participating institutions in the United States.1 The registry has been used to identify incidence and risk factors for anesthesia and procedure related adverse events.2-4 The C3PO Registry has been used once to examine anesthesia related adverse events; Lin et al4 reported that 94 of 13 611 (0.69%) C3PO cases between 2007 and 2010 had “serious sedation/airway adverse events”.4 We used the University of Virginia's (UVA) C3PO data collected between January 2016 and April 2021 to determine UVA's incidence of anesthesia related severe adverse events in patients undergoing congenital cardiac catheterizations during that 5 year period. The Institutional Review Board of UVA Health System approved this review. We identified 1281 cases in our C3PO database occurring during the study period, which represented all congenital cardiac catheterization performed during that period. Of those cases, 374 (29.2%) were endomyocardial biopsies, 563 (44%) were interventional procedures, and 344 (26.9%) were diagnostic procedures. Patients 18-years-old and younger constituted 90% of all cases. Percentages of cases utilizing general anesthesia, anesthesiologist administered sedation, and nurse administered sedation were 84.8%, 7.5%, and 7.7%, respectively. We identified 113 cases (8.8%) with adverse events and searched those 113 using keywords to identify 46 cases with possible anesthesia related adverse events. All C3PO data entry uses an established scoring system for adverse events that labels severity from one to five, with five being most severe.1, 3 We reviewed all 46 cased and identified 11 with severity levels from three to five, referred to below as “severe anesthesia related events” that correlated with events that were life threatening if not treated or resulted in patient death. Severe anesthesia related events occurred during five interventional cases, five diagnostic cases and one endomyocardial biopsy. Our incidence of severe anesthesia related events was 0.86%, and those events constituted 9.7% of total adverse events. Our chart review identified hypoxemia during the peri-anesthesia period in 10 of our 11 cases with severe anesthesia related events (Table 1), and all 10 of those received general anesthesia. Death occurred in one patient who had a failing single ventricle and suffered hypoxemia and hypotension followed by cardiac arrest during induction. Infants with single ventricle physiology comprised seven of 11 severe anesthesia related events. We examined univariate risk factors for severe anesthesia related events using Firth's penalized-likelihood logistic regression modeling5, 6 in the “logistf” package of R version 4.1.2. The odds of a severe anesthesia related event during interventional procedures and during diagnostic catheterizations, compared to odds during endomyocardial biopsies, were 2.45 (95% CI = 0.49, 23.98, p = .295) and 4.03 (95% CI = 0.80, 39.47, p = .094), respectively. For patients under 18 years of age (n = 1149), the odds of a severe anesthesia related adverse event decreased with each increasing year in age (OR = 0.66, 95% CI = 0.30, 0.92, p = .003), as shown in Figure 1. Our incidence of 0.86% for severe anesthesia related events in patients undergoing cardiac catheterization for congenital heart disease was similar to Lin et al's 0.69% incidence from C3PO data in 2007–2010.4 Severe anesthesia related adverse events at UVA during our study epoch constituted 9.7% of all adverse events, nearly identical with the breakdown in Lin's earlier composite data.2 Our single center data suggest little change in those percentages despite MRI or CT imaging replacing catheterization for some diagnostics and regular introduction of newer and more aggressive interventional procedures. The preponderance of infants with single ventricle physiology in our cohort with severe anesthesia related events is expected given the Pediatric Perioperative Cardiac Arrest Registry's high peri-anesthesia mortality in that patient group.7 Our single institution univariate risk factor analysis incorporates small patient numbers and therefore has limited power to detect statistically meaningful differences. Our risk analysis does not control for potential confounders because meaningful risk stratification of that type would have required considerably larger patient numbers. Our univariate association of decreasing age with greater odds of serious anesthesia related events agrees with Lin et al's univariate data on age and their multivariate data on patient weight.4 Participating C3PO institutions can benchmark their performance against composite data and against their own historic data. Either comparison can indicate need for a system review and quality improvement initiatives. The C3PO database is cardiologist designed and adjudicated and therefore is less oriented toward anesthesia related adverse events. A C3PO offshoot is being formed called the Anesthesia Outcomes Project to specifically analyze anesthesia related adverse events during pediatric cardiac catheterizations. We hope that effort will better define anesthesia specific outcomes and associated factors and provide answers to important questions such as what anesthesia techniques and what type of anesthesiologist are needed for particular patient and procedure types. The data that support the findings of this study are available from the corresponding author upon reasonable request