Ventilation strategies and risk factors for intraoperative respiratory critical events and postoperative pulmonary complications in neonates and small infants: a secondary analysis of the NECTARINE cohort^☆

\ua9 2025 The Author(s)Background: Optimal ventilation strategies and use of neuromuscular blocking agents (NMBAs) in neonates and small infants undergoing anaesthesia remain unclear. We examined the association of perioperative ventilation strategies and administration of NMBAs on respiratory adverse events in the NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) cohort. Methods: We performed a secondary analysis of NECTARINE, which included infants up to 60 weeks\u27 postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures. The primary endpoint was the association between ventilation mode and intraoperative respiratory adverse events. Secondary endpoints were use of NMBA, and 30-day postoperative pulmonary complications (PPCs). Results: The dataset comprised 5609 patients undergoing 6542 procedures. Pressure-controlled ventilation was the primary ventilation modality, accounting for 52.4% (n=3428) of cases. The incidence of intraoperative respiratory critical events was 20.7% (95% confidence interval [CI] 19.7–21.7%), while PPCs were observed in 17% of cases (95% CI 16.0–18.1%). Preanaesthesia respiratory conditions and NMBA use after tracheal intubation were associated with higher incidence of PPCs. Of the children receiving NMBAs, reversal was reported in 29.8%. The absence of reversal was associated with a higher incidence of PPCs, with a relative risk of 1.50 (95% CI 1.17–1.93). Conversely, NMBA reversal was associated with a reduced relative risk of 0.43 (95% CI 0.26–0.70). Conclusions: Regardless of ventilation strategy used, mechanical ventilation and baseline respiratory conditions were risk factors for a greater incidence of adverse respiratory events and PPCs. Reversal of NMBAs before tracheal extubation was significantly associated with reduced PPCs in neonates and should be routine clinical practice. Clinical trial registration: ClinicalTrials.gov (NCT02350348)

Perioperative critical events and morbidity associated with anesthesia in early life: subgroup analysis of United Kingdom participation in the neonate and children audit of anesthesia practice in Europe (NECTARINE) prospective multicenter observational study

BACKGROUND: The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective observational study reported critical events requiring intervention during 35.2% of 6542 anesthetic episodes in 5609 infants up to 60 weeks postmenstrual age. The United Kingdom (UK) was one of 31 participating countries. METHODS: Subgroup analysis of UK NECTARINE cases (12.8% of cohort) to identify perioperative critical events that triggered medical interventions. Secondary aims were to describe UK practice, identify factors more commonly associated with critical events, and compare 30-day morbidity and mortality between participating UK and non-UK centers. RESULTS: Seventeen UK centers recruited 722 patients (68.7% male, 36.1% born preterm, 48.1% congenital anomalies) undergoing anesthesia for 876 surgical or diagnostic procedures at 25-60 weeks postmenstrual age. Repeat anesthesia/surgery was common: 17.6% patients prior to and 14.4% during the recruitment period. Perioperative critical events triggered interventions in 300/876 (34.3%) cases. Cardiovascular instability (16.9% of cases) and/or reduced oxygenation (11.4%) were more common in younger patients and those with co-morbidities or requiring preoperative intensive support. A higher proportion of UK than non-UK cases were graded as ASA-Physical Status scores >2 or requiring urgent or emergency procedures, and 39% required postoperative intensive care. Thirty-day morbidity (complications in 17.2%) and mortality (8/715, 1.1%) did not differ from non-UK participants. CONCLUSIONS: Perioperative critical events and co-morbidities are common in neonates and young infants. Thirty-day morbidity and mortality data did not demonstrate national differences in outcome. Identifying factors associated with increased risk informs preoperative assessment, resource allocation, and discussions between clinicians and families