Unreported deaths in pediatric surgery and anesthesia: a national, twenty year report

Introduction. Pediatric perioperative mortality is extremely low but it is underreported in peer-reviewed journals, making it difficult to understand the magnitude of the problem. The aim of this study was to identify pediatric deaths reported by the mass media over a 20year period in pediatric and non-pediatric hospitals. Materials and methods. The international search engines Google, Yahoo, Bing, and the online archives of major newspapers were searched independently by 3 trained investigators (1st January 1995 to 1st January 2015) looking for children (<18 years old) who died in the perioperative period in Italy, excluding obstetrical or neonatal deaths. Results. A total of 51 fatal events were identified with 41 cases (80%) being elective procedures. Most fatal events (31 cases, 61%) occurred in non-specialized hospitals, 12 cases (23%) occurred in high-volume non-pediatric hospitals, and 8 cases (16%) in pediatric hospitals. The most frequently represented operations were head/ neck 21 cases (41%), abdominal 11 cases (21%), and orthopedic surgery 9 cases (18%). The reported causes of death were equally distributed between surgical (25 cases, 49%) and anesthesiological complications. The most common causes of death were hemorrhage (n=11), difficult airway management (n=10), infections (n=6), and allergic reactions (n=4). In 25% of cases (13 cases), the complication resulted in intraoperative death. Conclusion. Our findings suggest that most pediatric deaths reported by mass media occurred in non-pediatric centers during elective surgical procedures (e.g. adenotonsillectomy and appendicectomy), suggesting that referral to large-volume or pediatric hospitals should be preferred. Moreover, one of the most commonly reported complications was difficult airway management, confirming that this aspect should have a central role in physician training and practice.