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. 2025 Feb 19:S0007-0912(25)00058-3.
doi: 10.1016/j.bja.2024.12.038. Online ahead of print.

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☆

Alexander Fuchs  1 , Nicola Disma  2 , Thomas Engelhardt  3 , Vanessa Marchesini  4 , Thomas Riedel  5 , Krisztina Boda  6 , Walid Habre  7 , Thomas Riva  8 ; NECTARINE Steering Committee; Nicola Disma  9 , Francis Veyckemans  10 , Katalin Virag  6 , Tom G Hansen  11 , Karin Becke-Jakob  12 , Pierre Harlet  13 , Laszlo Vutskits  14 , Suellen M Walker  15 , Jurgen C de Graaff  16 , Marzena Zielinska  17 , Dusica Simic  18 , Thomas Engelhardt  19 , Walid Habre  14 ; NECTARINE Group of the European Society of Anaesthesiology and Intensive Care Clinical Trial Network
Collaborators, Affiliations
Free article

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☆

Alexander Fuchs et al. Br J Anaesth. .
Free article

Abstract

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' 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).

Keywords: intraoperative respiration; mechanical ventilation; neonate; neuromuscular blocking agent; paediatric; postoperative pulmonary complications; respiratory adverse events.

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Conflict of interest statement

Declaration of interest TE is a member of the associate editorial board of the British Journal of Anaesthesia. The other authors declare that they have no conflicts of interest.

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