Article Data

  • Views 264
  • Dowloads 146


Open Access Special Issue

Why complex surgeries in children are associated with poorer outcomes

  • Mathias Johansen1
  • Vincent Collard1
  • Thomas Engelhardt1

1Department of Anesthesia, McGill University Health Center, Montreal Children's Hospital, Montreal, QC, Canada

DOI: 10.22514/sv.2021.060

Online publish date: 07 April 2021

*Corresponding Author(s): Mathias Johansen E-mail:


Despite obvious progress in perioperative morbidity and mortality we still face challenges in explaining why complex surgical procedures in children are associated with poorer outcomes. This review aims to address the importance of improving perioperative outcome through the implementation of strategies for quality assurance and the safe conduct of paediatric anaesthesia.


Complex surgery; Paediatric; Anaesthesia; Mortality; Morbidity; Caseload; Quality; Education; Neurotoxicity; Safetots

Cite and Share

Mathias Johansen,Vincent Collard,Thomas Engelhardt. Why complex surgeries in children are associated with poorer outcomes. Signa Vitae. 2021.doi:10.22514/sv.2021.060.


[1] Weiss M, Vutskits L, Hansen TG, Engelhardt T. Safe anesthesia for every tot - the SAFETOTS initiative. Current Opinion in Anaesthesiology. 2015; 28: 302-307.

[2] Vutskits L, Culley DJ. GAS, PANDA, and MASK: no evidence of clinical anesthetic neurotoxicity! Anesthesiology. 2019; 131: 762-764.

[3] Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW. A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology. 1993; 78: 461-467.

[4] Raviraj D, Engelhardt T, Giedsing Hansen T. Safe anesthesia for neonates, infants and children. Minerva Pediatrica. 2018; 70: 458-466.

[5] Jevtovic-Todorovic V, Hartman RE, Izumi Y, Benshoff ND, Dikranian K, Zorumski CF, et al. Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. The Journal of Neuroscience. 2003; 23: 876-882.

[6] FDA. FDA drug safety communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. 2016. Available at: https://www.fda. gov/Drugs/DrugSafety/ucm532356.htm (Accessed: 05 December 2020).

[7] FDA. FDA drug safety communication: FDA approves label changes for use of general anesthetic and sedation drugs in young chil-dren. 2017. Available at: (Accessed: 05 December 2020).

[8] Jimenez N, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. An update on pediatric anesthesia liability: a closed claims analysis. Anesthesia & Analgesia. 2007; 104: 147-153.

[9] Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, et al. Anesthesia-related cardiac arrest in children: update from the pediatric perioperative cardiac arrest registry. Anesthesia and Analgesia. 2007; 105: 344-350.

[10] Goyal A, Lu VM, Yolcu YU, Elminawy M, Daniels DJ. Endoscopic versus open approach in craniosynostosis repair: a systematic review and meta-analysis of perioperative outcomes. Child’s Nervous System. 2018; 34: 1627-1637.

[11] Lee HQ, Hutson JM, Wray AC, Lo PA, Chong DK, Holmes AD, et al. Analysis of morbidity and mortality in surgical management of craniosynostosis. Journal of Craniofacial Surgery. 2012; 23: 1256-1261.

[12] Lal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, et al. Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula. Journal of Pediatric Surgery. 2017; 52: 1245-1251.

[13] Oomen MW. Systematic review of the literature: comparison of open and minimal access surgery (thoracoscopic repair) of esophageal atresia with tracheo-esophageal fistula (EA-TEF). In Nazari S (ed.) Front Lines of Thoracic Surgery (pp. 309-320). IntechOpen. 2012.

[14] Leeuwen L, Fitzgerald DA. Congenital diaphragmatic hernia. Journal of Paediatrics and Child Health. 2014; 50: 667-673.

[15] Dingeldein M. Congenital diaphragmatic hernia: management & outcomes. Advances in Pediatrics. 2018; 65: 241-247.

[16] Wang Y, Honeyford K, Aylin P, Bottle A, Giuliani S. One-year outcomes for congenital diaphragmatic hernia. BJS Open. 2019; 3: 305-313.

[17] Brown KL, Pagel C, Ridout D, Wray J, Anderson D, Barron DJ, et al. What are the important morbidities associated with paediatric cardiac surgery? A mixed methods study. BMJ Open. 2019; 9: e028533.

[18] Green MD, Parker DM, Everett AD, Vricella L, Jacobs ML, Jacobs JP, et al. Cardiac biomarkers associated with hospital length of stay after pediatric congenital heart surgery. The Annals of Thoracic Surgery. 2020: S0003-4975(20)31354-0

[19] Liu M, Druschel CM, Hannan EL. Risk-adjusted prolonged length of stay as an alternative outcome measure for pediatric congenital cardiac surgery. The Annals of Thoracic Surgery. 2014; 97: 2154-2159.

[20] Spector LG, Menk JS, Knight JH, McCracken C, Thomas AS, Vinocur JM, et al. Trends in long-term mortality after congenital heart surgery. Journal of the American College of Cardiology. 2018; 71: 2434-2446.

[21] Tai D, Dick P, To T, Wright JG. Development of pediatric comorbidity prediction model. Archives of Pediatrics & Adolescent Medicine. 2006; 160: 293-299.

[22] Stolwijk LJ, Lemmers PM, Harmsen M, Groenendaal F, de Vries LS, van der Zee DC, et al. Neurodevelopmental outcomes after neonatal surgery for major noncardiac anomalies. Pediatrics. 2016; 137: e20151728.

[23] Disma N, Leva B, Dowell J, Veyckemans F, Habre W. Assessing anaesthesia practice in the vulnerable age group: NECTARINE: a European prospective multicentre observational study. European Journal of Anaesthesiology. 2016; 33: 233-235.

[24] Auroy Y, Ecoffey C, Messiah A, Rouvier B. Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics. Anesthesia and Analgesia. 1997; 84: 234-235.

[25] NCEPOD. National confidential enquiries into perioperative death. 1993. Available at: (Accessed: 05 December 2020).

[26] Harrison TE. Engelhardt T. McFarlane F, Flick RP. Regionalization of pediatric anaesthesia care: has the time come? Paediatric Anaesthesia. 2014; 24: 897-898.

[27] Danish Health Authorities. Recommendations from the Danish Health Authority. Thesis Guidance Anaethesiology. 2020. Available at:æstesiologi/SST_Specialevejledning_ for_Anaestesiologi-03072020.ashx?la=da&hash= 6B3BB5148B1CD0F7AE9035038D3AA05E08997EDA (Accessed: 05 December 2020).

[28] ADARPEF. Recommendations from L’association des Anesthésistes Réanimateurs Pédiatriques d’Expression Française (ADARPEF) / So-ciété Française d’Anesthésie et de Réanimation (SFAR). 2004. Avail-able at: (Accessed: 05 December 2020).

[29] Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. The Lancet Respiratory Medicine. 2017; 5: 412-425.

[30] Stricker PA, de Graaff JC, Vutskits L, Muhly WT, Xu T, Torborg AM, et al. Pediatric perioperative outcomes group: defining core outcomes for pediatric anesthesia and perioperative medicine. Pediatric Anesthesia. 2018; 28: 314-315.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

IndexCopernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 0.5(2019) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time