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Perioperative Paediatric Cardiac Arrest Study – A Case of Duplication?
- Santosh I Patel, Sanjay Bhananker (30 March 2007)
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Perioperative Paediatric Cardiac Arrest Study – A Case of NO Duplication
- Jose RC Braz, Leandro G Braz, Norma SP Modolo and Paulo do Nascimento Junior (30 March 2007)
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Potentially preventable!
- Balamurugan Ramalingam (2 May 2006)
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Santosh I Patel Acting Assistant Professor, Sanjay Bhananker
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Dear Editor, We read with interest the article by Braz et al (May, 2006).1 It appears that part of this study (pertaining to cardiac arrests in the paediatric age group) has been published a few months later in Paediatric Anaesthesia (PA) (August, 2006). 2 The paediatric cases from table 6 (BJA) and much of the discussion is reproduced in this later publication with minimal changes. Both the studies were conducted over a 9 year period. We have briefly described the results form these publications in Table 1. Results from a common (overlapping) eight years and nine month period (April 1996 to December 2004) are reported in each of the publications. Thus, paediatric patients in each of these studies have a “unique” period of only three months and an overlapping period of 105 months. We think that a three months difference over a nine years period is insufficient to warrant a republication. It appears that there are significant differences in the data of these publications despite the near identical periods of the studies. The incidence of cardiac arrest (CA) in the paediatric group in PA publication is 35 in 9 years, while the publication in BJA (3 months late but same period) reports 40 cardiac arrests. The total number of cases in the 31 days to < 1 year age group are reported the same (2368 cases) in both the articles (coincidence!) while the number of CA in BJA publication was much higher (13) vs. 10 in the PA publication. We also wish to comment on the method of reporting the incidence of CA. Since perioperative CA are relatively rare phenomena, the incidence is traditionally reported in “per 10,000” anaesthetics. In this instance, incidences of 27 per 10,000 paediatric anaesthetics (BJA) and 23 per 10,000 (PA) anaesthetized children are reported from the same institution. When looking at 31 days – 1 year age group, the incidences reported are 55 and 42 per 10,000 anaesthetics respectively. We believe that reporting these incidences per 1,000 anaesthetics would be more appropriate. We have not done any statistical analysis to see if these different incidence rates would be statistically significant. If indeed they were, it would be strange to have the same group of investigators from the same institution studying the same patient population over a similar time period and coming up with “different” results. We also found the difference in the total numbers of anaesthetics performed in the various paediatric age groups in the two studies interesting. A total of 697 anaesthetics were administered for patients in the 0-30 days age group in 9 years (an average of 6.4 neonatal anesthetics per month), while the study reported in BJA quotes 149 more anesthetics in the same age group in just 3 months (an average of 50 anaesthetics per month) In neither of the publications have the authors cited their “other work” being submitted to another journal for possible publication. We believe this is a case of duplicating the publication though technically the authors have violated no grounds by having a “unique” 3 month period for each study. Santosh I. Patel, MD, FRCA Acting Assistant Professor Sanjay M. Bhananker, MD, FRCA Assistant Professor References: 1. Braz LG, Modolo NSP, Bruschi BAM et al: Perioperative cardiac arrest: a study of 53 718 anaesthetics over 9 yr from a Brazilian teaching hospital. Brit J Anaesth 2006; 96: 569-75 2. Braz LG, Braz JRC, Modolo NSP et al. Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital. Paedia Anaesth 2006; 16: 860-66 Conflict of Interest:None declared |
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Jose RC Braz, Full Professor UNESP - São Paulo State University, Leandro G Braz, Norma SP Modolo and Paulo do Nascimento Junior
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Dear Editor, We read the comments by Patel & Bhananker1 concerning our publications (Braz et al 2,3) and the possibility of duplication. To verify the possibility of duplication in two different publications about the same subject (incidence of cardiac arrest), firstly, it is necessary to verify the main objectives of the studies. While the study about cardiac arrests published in Br J Anaesth 2 aimed to study the incidence, causes, and outcome of all cardiac arrests in all surgical patients of all ages anaesthetized during a 9-year period (April 1, 1996 to March 31, 2005), the publication in Paediatr Anaesth 3 had the purpose of studying the incidence, causes and outcome of the cardiac arrests specifically in the paediatric patients in a 9-year period (January 1, 1996 to December 31, 2004). Both studies were performed in the same Brazilian Tertiary Hospital but their objectives were very clearly distinct. It can be verified that the study involving all ages 2 presents the incidence of cardiac arrests of all age groups, from neonates to the elderly. In this study, the risk factors, as ASA physical status classification, gender, surgical area, surgical procedures (elective, urgent, and emergency), anaesthetic technique, causes of cardiac arrest (patient disease/condition, surgery or anaesthesia), and adverse events in cardiac arrests related to anaesthesia are shown for all ages and do not consider age groups. Most of the discussion compares the results for all ages with the results described by other researchers who studied incidence and causes of cardiac arrests in all ages, as well. The authors briefly comment the higher rate of cardiac arrests in neonates and children from 31 days to < 1 year, and in advanced age (≥ 65 yr). In our study concerning the paediatric population 3, the incidence of cardiac arrest is shown according to paediatric age groups, and the risk factors are shown for all paediatric population. The discussion is elaborated on the comparison of our results with those described by other studies in the paediatric population. When an analysis of our two studies 2,3 is done, it is verified that just one of them 3 makes clear the risk factors that are specific for cardiac arrest incidence in the paediatric population. We also used different filters on the database to acquire the data for our two studies. The reason is that a lot of procedures performed in adult population are done with no anaesthesiologist assistance (i.e. endoscopy, bone marrow puncture, pacemaker implantation, small surgical procedures, broncoscopy etc.) and these procedures were filtered out of the study 2, for both children and all other age groups. On the other hand, in paediatric patients all of these procedures are performed with the assistance of anaesthesiologists and, therefore, they were included in the pediatric study 3. Then, the nonselective filter applied to the database in our Br J Anaesth publication 2 reduced the number of children and made the size of paediatric population different from Paediatr Anaesth publication 3. Furthermore, concerning the paediatric population, there is a period of time that is not common for both studies. Both studies involved 105 months with a 3-month difference between the periods which resulted in a 6 -month non overlapping time, exactly the edges. We highlight that between January 1 - March 31, 1996 and January 1 - March 31, 2005 there was a 9- year interval. And, considering the edges, there is a significant difference in the characteristics of the population. In other words, the hospital has changed a lot and in the first three months of 1996, the number of anaesthetic procedures in neonates (0-30 days) was very low (1 a 4 cases/month) as compared to several dozens, approximately 50 cases/month in the first 3 months of 2005. Obviously, the increase in neonate cases was not abrupt but has progressively happened, mainly in the last years of the period of the study. The reason for this higher number of neonate cases is that the University Hospital became reference for high-risk obstetric and newborn patients and there has been an increase in the number of beds for this specific group of patients. Thus, it makes no sense to analyze neonate procedures as monthly mean because it does not represent what has happened in the 9-year period of study. There has also been a significant increase in neonates and children clinically classified as ASA III physical status or higher, and emergence surgeries (Table 1), as well, which are major risk factors for cardiac arrest. These facts explain the higher incidence of cardiac arrests in children aged 31 days to < 1 year in Br J Anaesth 2, 13 cases versus 10 cases in Paediatr Anaesth 3 publication, despite the same total number of cases in this age group (coincidently the same, 2,368 cases) in both articles. There was a small increase (2 cases) in the number of cardiac arrests in the other groups of ages. The result was an increase in the incidence of cardiac arrests to 27:10,000 in pediatric anesthetics 2 compared to 23:10,000 3. These results are not unexpected if we consider the increase in risk factors in neonates and children. Furthermore, the changes in risk factors also make the paediatric population from Paediatr Anaesth 3 different that from B J Anaesth 2 and they can not be considered the same population. Thus, different studies with distinct focuses (and for this reason, different filters were applied to the database), and the change in the paediatric population profile make the studies different what may result in misinterpretation as that by Patel & Bhananker1. The first manuscript to be submitted was that in Paediatr Anaesth, on August 18, 2005 whereas the submission of the manuscript in Br J Anaesth took place later, on November 31, 2005, what made possible the report of more recent data about the incidence of cardiac arrest. Paediatr Anaesth accepted the manuscript for publication on December 8, 2005 and Br J Anaesth did it on February 15, 2006. Thus, when the manuscript was submitted to Br J Anaesth, we had not had any position of Paediatr Anaesth yet and for this reason we did not cite our works in any manuscript. Well, maybe we should have done and we apologize for it. Recent literature on paediatric cardiac arrests and mortality is scarce 4-6. What we consider extremely important is that the incidence of cardiac arrests in the paediatric population during anaesthesia in our Hospital (22,9: 10,000 anaesthetics 3) is higher than that seen in more recent publications 4-6. Thus, it is important to report the incidence of cardiac arrests in the different age groups in paediatric patients and compare them with other publications and reports. We think that the analysis of the causes is more important and much more instructive than the incidence, as the comparison of the incidence between studies can be very difficult due to differences in methodology. The publications 2,3 had different objectives and there are differences in paediatric populations. Thus, we believe that this is NOT a case of duplication. Leandro Gobbo Braz MD, PhD Norma S P Modolo MD, PhD Paulo do Nascimento Jr MD, PhD José Reinaldo C Braz MD, PhD Department of Anesthesiology, School of Medicine São Paulo State University Botucatu, São Paulo State, Brazil (email: jbraz@fmb.unesp.br) References: 1. Patel SI, Bhananker SM. Perioperative paediatric cardiac arrest study – A case of duplication? Br J Anaesth 2. Braz LG, Modolo NS, do Nascimento P Jr, et al. Perioperative cardiac arrest: a study of 53,718 anaesthetics over 9 yr from a Brazilian teaching hospital. Br J Anaesth. 2006 May;96:569-75. 3. Braz GL, Braz JR, Modolo NS, et al. Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital. Paediatr Anaesth. 2006 Aug;16:860-6. 4. Morray JP, Geiduschek JM, Ramamoorthy C, et al. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology. 2000 Jul;93:6-14. 5. Murat I, Constant I, Maud'huy H. Perioperative anaesthetic morbidity in children: a database of 24,165 anaesthetics over a 30-month period. Paediatr Anaesth. 2004 Feb;14:158-66. 6. Flick RP, Sprung J, Harrison TE, et al. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients. Anesthesiology 2007 Feb;106:226-37. Conflict of Interest:None declared |
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Balamurugan Ramalingam, SHO, Anaesthetics QEQM hospital, Margate
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Dear Editor, I am writing in resonse to the interesting article on peri-operative cardiac arrest. Thanks to Braz et al for their extensive work on peri-operative cardiac arrest. It is quite interesting to see that it quite rightly reflects the fact that most of anaesthesia related deaths are due to airway problems and during emergencies. It emphasises the importance of maintaining and improving airway management skills and following NCEPOD recommendations. Most of the airway related problems are potentially preventable. Also a note to be added regarding training the anaesthetists for the management of anaphylaxis which is often theorotical. We need to stress the importance of application of simulators in training anaesthetists and other theatre staff in the management of such rare but life threatening events. I would like to share my experience and need some clarification. It happened while I was working in India. It was a 25 year old male patient, a known Intravenous opioid abuser scheduled to undergo decompression for cellulitis-right arm. The last time he took opioid was 48 hours ago. He was given general anaesthesia with spontaneous ventilation. He received 200 micrograms of fentanyl for analgesia. Half way through surgery he suddenly developed ventricular tachycardia not responding to lignocaine. It then progressed to pulseless ventricular tachycardia which was successfully resuscitated by DC cardioversion. I would like to know if you would classify this as anaesthesia related event or patient's condition related event. Thanks! Conflict of Interest:None declared |
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