Abstract
BACKGROUND: The NEonate and Children audiT of Anesthesia pRactice IN Europe (NECTARINE) study, led by the ESAIC Clinical Trials Network, collected prospective data on 5609 children up to 60 weeks postmenstrual age undergoing 6542 anesthetic procedures across 165 centers in 31 European countries (ESAIC_CTN_NECTARINE). While the study provides comprehensive European data, healthcare systems, perioperative practices, and organizational standards vary considerably between countries. Germany was selected a priori for a dedicated subcohort analysis due to its substantial contribution (10.3% of the total dataset) and notable differences to other European countries in the absence of a centralization and national training program in pediatric anesthesia. This focused evaluation aimed to benchmark national data against European findings, identify country-specific strengths and weaknesses, and support targeted quality improvement and guideline development within the German healthcare system. AIMS: To compare the incidence, nature, and consequences of perioperative critical events between the German and non-German NECTARINE cohorts and to assess practice-related risk factors and outcomes. METHODS: Data from 14 German centers were analyzed using mixed-effects logistic regression to examine associations between critical events and 30-day morbidity and mortality. Perioperative management practices and risk profiles were compared with those from the rest of the European cohort. RESULTS: The German cohort showed a significantly higher rate of critical events (47.0% vs. 33.9%, p < 0.001), with cardiovascular instability being most frequent (82.6%). Within German centers, the occurrence of a critical event nearly tripled the risk of postoperative complications within 30 days (OR: 2.85; 95% CI: 1.67-4.87). ASA status and number of surgeries were also significant predictors of morbidity. CONCLUSIONS: This prospectively defined subanalysis demonstrates that perioperative outcomes and practice patterns in Germany differ from European averages, particularly regarding the frequency of critical events, thresholds for intervention, staffing ratios, and complication profiles. These insights highlight the need for targeted interventions in German pediatric anesthesia, contribute to contextualizing European data, and offer baseline data for future cross-border quality initiatives and trials. TRIAL REGISTRATION: ClinicalTrails.gov NCT02350348.