Anesthesia-Related and Perioperative Cardiac Arrest in Low- and High-Income Countries: A Systematic Review With Meta-Regression and Proportional Meta-Analysis

The anesthesia-related cardiac arrest (CA) rate is a quality indicator to improve patient safety in the perioperative period. A systematic review with meta-analysis of the worldwide literature related to anesthesia-related CA rate has not yet been performed. This study aimed to analyze global data on anesthesia-related and perioperative CA rates according to country's Human Development Index (HDI) and by time. In addition, we compared the anesthesia-related and perioperative CA rates in low- and high-income countries in 2 time periods. A systematic review was performed using electronic databases to identify studies in which patients underwent anesthesia with anesthesia-related and/or perioperative CA rates. Meta-regression and proportional meta-analysis were performed with 95% confidence intervals (CIs) to evaluate global data on anesthesia-related and perioperative CA rates according to country's HDI and by time, and to compare the anesthesia-related and perioperative CA rates by country's HDI status (low HDI vs high HDI) and by time period (pre-1990s vs 1990s–2010s), respectively. Fifty-three studies from 21 countries assessing 11.9 million anesthetic administrations were included. Meta-regression showed that anesthesia-related (slope: −3.5729; 95% CI: −6.6306 to −0.5152; P = 0.024) and perioperative (slope: −2.4071; 95% CI: −4.0482 to −0.7659; P = 0.005) CA rates decreased with increasing HDI, but not with time. Meta-analysis showed per 10,000 anesthetics that anesthesia-related and perioperative CA rates declined in high HDI (2.3 [95% CI: 1.2–3.7] before the 1990s to 0.7 [95% CI: 0.5–1.0] in the 1990s–2010s, P < 0.001; and 8.1 [95% CI: 5.1–11.9] before the 1990s to 6.2 [95% CI: 5.1–7.4] in the 1990s–2010s, P < 0.001, respectively). In low-HDI countries, anesthesia-related CA rates did not alter significantly (9.2 [95% CI: 2.0–21.7] before the 1990s to 4.5 [95% CI: 2.4–7.2] in the 1990s–2010s, P = 0.14), whereas perioperative CA rates increased significantly (16.4 [95% CI: 1.5–47.1] before the 1990s to 19.9 [95% CI: 10.9–31.7] in the 1990s–2010s, P = 0.03). Both anesthesia-related and perioperative CA rates decrease with increasing HDI but not with time. There is a clear and consistent reduction in anesthesia-related and perioperative CA rates in high-HDI countries, but an increase in perioperative CA rates without significant alteration in the anesthesia-related CA rates in low-HDI countries comparing the 2 time periods.