Adverse Events in Radiation Oncology: A Case Series from Wake Up Safe, the Pediatric Anesthesia Quality Improvement Initiative

Abstract

Background

Radiation therapy in pediatric patients often requires anesthesia and poses environmental challenges. Monitoring must be done remotely to limit radiation exposure to the provider. Airway access can be limited by masks or frames. Care is often delivered in relatively inaccessible locations in the hospital. While individual institutions have reported their outcomes, this case series aims to review a multicenter registry of significant adverse events (SAE) and make recommendations for improved care.

Methods

Wake Up Safe: The Pediatric Quality Improvement Initiative maintains a multi‐site, voluntary registry of pediatric peri‐anesthetic SAE. This was queried for reports from radiation oncology from January 1, 2010 to May 10, 2018. The database contained 3,379 SAE from approximately 3.3 million anesthetics. All 33 institutions submitted data on a standardized form (Supplemental Appendix 1) to a central data repository (Axio Research, Seattle Washington). Prior to each SAE case submission, three anesthesiologists who were not involved in the event analyzed the event using a standardized root cause analysis method to identify the causal or contributing factor(s).

Results

Six SAE were identified. In three, incorrect programming of a propofol infusion resulted in overdose. In case one, the 3 year old female became hypotensive, requiring vasopressors and volume resuscitation. In the second, the 2 year old female experienced airway obstruction and apnea resquiring chin lift. In case three, the child suffered no consequences despite a noted overdose of propofol infusion. In case four, a 2 year old female with recent respiratory infection suffered laryngospasm during an unmonitored transport to the recovery area. She developed profound oxygen desaturation with bradycardia treated with succinylcholine and chest compressions. In case five, a 6 year old former premature child suffered laryngospasm at the conclusion of mask creation under general anesthesia with a laryngeal mask airway. The radiation mask delayed recognition of copious secretions. Finally, in case six, a 6 year old undergoing stereotactic radiosurgery in a head halo suffered bronchospasm and unintended extubation during therapy which required multiple attempts at re‐inbuation by multiple providers ultimately requiring cancellation of the treatment and transport to the intensive care unit.

Conclusions

There were few radiation oncology SAE, but analysis has led to the identification of several specific opportunities for improvement in pediatric anesthesia for radiation oncology.

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