Distribution and Outcomes of Paediatric Anaesthesia Services in Sweden: An Epidemiological Study

Academic Background

In recent years, there has been a growing trend towards the centralization of perioperative care for children globally, particularly in European countries. This trend is primarily driven by research findings from professional organizations, which indicate a positive correlation between the experience of the anesthesia team and surgical outcomes. For example, international audit projects such as APRICOT and NECTARINE have shown that experienced anesthesia teams can significantly reduce the incidence of surgical complications. Additionally, the Safetots initiative proposes that specially trained pediatric anesthesiologists should provide anesthesia services for children under 3 years of age with congenital or metabolic diseases, as well as for children undergoing major or complex surgeries. This initiative is based on the fact that the incidence of anesthesia-related complications in children is higher than in adults, and the experience level of the anesthesiologist is inversely related to the incidence of complications.

However, despite the theoretical advantages of centralized care, data on the ideal and actual distribution of pediatric anesthesia services at the national level, as well as the rates of complications and mortality at different levels of care, remain scarce. Sweden, as a sparsely populated country, faces the challenge of balancing centralized care with the capabilities of local hospitals. Therefore, this study aims to analyze nationwide pediatric anesthesia data in Sweden to explore the distribution of anesthesia services, the incidence of complications, and mortality rates, providing a scientific basis for future policy-making.

Source of the Paper

This paper was co-authored by Björn Bergh-Eklöf, Karl Stattin, Ali-Reza Modiri, Robert Frithiof, and Peter Frykholm from Uppsala University, Sweden, and published in the British Journal of Anaesthesia on August 1, 2024. The study is based on data from the Swedish Perioperative Register (SPOR), covering 214,964 pediatric anesthesia procedures performed in Sweden between 2019 and 2022.

Research Process

Data Source and Processing

This study is a registry-based cohort study, with data sourced from the Swedish Perioperative Register (SPOR). The SPOR system records detailed information on all anesthesia procedures performed in Sweden, including the date of surgery, type of anesthesia, and airway management. The research team extracted data from SPOR for all anesthesia procedures performed on children under 15 years of age between January 1, 2019, and December 31, 2022. The data were categorized by age group: neonates ( months), infants (2-12 months), toddlers (1-2 years), preschool children (3-5 years), and school-age children (6-15 years).

Hospital Classification and Surgical Distribution

The study classified hospitals into five categories: pediatric hospitals (university hospitals offering specialized pediatric services, including pediatric intensive care units), university hospitals (offering mixed adult and pediatric services), county hospitals (offering adult and pediatric services, with adult intensive care units and intermediate-level neonatal intensive care units), district hospitals (providing basic emergency services, possibly with pediatric services but no intensive care units), and small hospitals (offering only a few specialized services, with no intensive care units or regular pediatric services). The study analyzed the distribution of anesthesia procedures across these hospital categories and provided detailed statistics by age group and ASA (American Society of Anesthesiologists) physical status classification.

Analysis of Complications and Mortality

The study analyzed the incidence of perioperative adverse events (AEs) and severe adverse events (SAEs). AEs were classified into five levels of severity: Grade 1 (no effect on postoperative care), Grade 2 (affects care in the post-anesthesia care unit but not further postoperative care), Grade 3 (affects postoperative care, requiring extended care or additional observation), Grade 4 (requires postoperative intensive care), and Grade 5 (may result in long-term morbidity or death). SAEs were defined as perioperative complications of Grade 4 or 5. Additionally, the study analyzed 24-hour and 30-day all-cause mortality.

Key Findings

Surgical Distribution

Between 2019 and 2022, a total of 214,964 pediatric anesthesia procedures were performed in Sweden, involving 145,693 children. Of these, 73% of neonatal and infant surgeries were performed in pediatric hospitals, and 21% were performed in other university hospitals. County hospitals primarily handled surgeries for older children. 97% of neonatal surgeries and 92% of infant surgeries were performed in pediatric hospitals or university hospitals.

Incidence of Complications

The overall incidence of AEs was 2.71%, and the incidence of SAEs was 0.067%. The most common AE was laryngospasm (0.42%), and the most common SAE was bronchospasm (1.3:10,000). The incidence of AEs varied across hospital categories, with pediatric hospitals having a lower incidence of AEs (2.6%) and university hospitals having a higher incidence (3.6%).

Mortality Rates

The 24-hour all-cause mortality rate was 6.6:10,000 anesthesia procedures, and the 30-day all-cause mortality rate was 14.7:10,000 anesthesia procedures. The 30-day mortality rate was highest in the neonatal population, at 286:10,000 anesthesia procedures. Most deaths occurred in pediatric hospitals and university hospitals, particularly among children with poorer ASA physical status (ASA≥3).

Conclusions and Significance

This study provides the first detailed description of the distribution of pediatric anesthesia services in Sweden and offers nationwide data on complications and mortality rates. The results indicate that most neonatal and infant surgeries are performed in tertiary centers (pediatric hospitals and university hospitals), while county hospitals primarily handle surgeries for older children. Although mortality rates are higher in tertiary centers, this reflects the fact that these hospitals treat children with higher comorbidity rates. The study also highlights the need for improvements in AE reporting within the SPOR system and calls for the development of international consensus to standardize the definitions and reporting principles for AEs.

Research Highlights

1. Nationwide Data: This study provides the first nationwide data on the distribution and outcomes of pediatric anesthesia services in Sweden, filling a gap in the field.
2. Centralization Trend: The study confirms the trend towards centralization of pediatric anesthesia services in tertiary centers and reveals its impact on complication and mortality rates.
3. Mortality Analysis: The study provides a detailed analysis of mortality rates across different hospital categories and age groups, offering important insights for future policy-making.
4. Data Improvement Recommendations: The study proposes recommendations for improving AE reporting in the SPOR system, providing direction for future data collection and analysis.

Other Valuable Information

The study also notes that, despite Sweden’s well-developed healthcare system, the challenge of balancing centralized care with the capabilities of local hospitals in sparsely populated areas remains. Future research should further explore how to ensure surgical safety while enhancing the anesthesia service capabilities of local hospitals.

This study provides important reference data for pediatric anesthesia services in Sweden and globally, offering a scientific basis for future policy-making and clinical practice improvements.