• anesthesia
• Anesthetic neurotoxicity
• Brain perfusion
• Morbidity
• mortality
• Near critical incidents
• pediatric

Children and parents fear anesthesia because of the risk of acute morbidity and mortality. Although anesthesiology has greatly improved patient safety through the years, pediatric anesthesia does not reach the same levels as adult anesthesia due to various reasons. The present document includes a review of the worldwide literature and aims to provide a snapshot of present and past rates of anesthesia-related pediatric mortality as well as overall perioperative pediatric mortality in pediatric anesthesia. Moreover, comments on the open debate about the problems of anesthesia with further consequences in the future such as those related to neurotoxicity, behavioral problems and perioperative anxiety.
As part of the analysis, current literature about pediatric anesthesia and perioperative care along the last half century was included. Studies were identified by searching PubMed (1966-2020). Each paper was revised to identify the author(s), the data source, the time period, the number of patients, the time of death, and the perioperative and anesthesia-related mortality rates. Forty-one authors were closely analyzed.
All the reviewed authors agree that the major risk factors for cardiac arrest and perioperative death are young age (neonates and children under 1 year old), ASA >III or poorer physical status, emergency surgery, and general anesthesia in cardiac, thoracic, or gastroenterological surgery as well as procedures in centers that are non-specialized in pediatric care. Despite these recent advantages, anesthesia in neonates and toddlers, and in children ASA class IV and V is still associated with increased hospital mortality (1 out of 25) which is mostly related to extreme prematurity and congenital (cardiac) abnormalities.
Modern anesthesia in children ASA class I to III above 1 year of age in high income countries has become very safe, in which the risk for mortality or morbidity with permanent deficits has reached safety levels, matching anesthesia for adults. This high level of safety has been achieved by the safety of mostly short acting drugs and intensified training and centralization of care. In contrast, anesthesia in children in low income countries is still associated with a high risk of mortality mostly because of shortage of delayed diagnosis and lack of basic resources and training of healthcare providers.
The study led to indicating that developed countries worldwide documented similar total anesthesia-related mortality rates (<1 death per 10,000 anesthetics) and declines in anesthesia-related mortality rates in the past decade. Furthermore, higher anesthesia-related mortality rates (4.9-20 per 10,000 anesthetics) were found in studies from developing countries over the same time period. 
From the actual data we can assert that pediatric anesthesia is relatively safe and that modern drugs, standard monitoring, use of surgical safe checklist and specific training are strongly related with a safer pediatric anesthesia.
In all the studies main causes of mortality and critical events were related with airway management and cardio circulatory. 
The data regarding anesthesia-related, near critical incidents and perioperative mortality rates may be useful in developing prevention strategies. Despite the low mortality, surgery and anesthesia in neonates for congenital malformations is also associated with disturbances in long term neurodevelopmental outcome at older age. Experimental research has suggested that the toxic effect of anesthetics might be cause of this impairment. However, the results from epidemiologic studies show conflicting results. Furthermore, the derangement might also be caused by insufficient brain perfusion in the period phase which emphasized the need for development of adequate techniques to monitor brain perfusion and oxygenation in the perioperative phase.