1. Although many cases of cardiac arrest in pediatric anesthesia are due to the child’s underlying condition(s), anesthetic-related events do account for a significant portion of arrests.
2. Among the anesthesia related causes for cardiac arrests in pediatrics, cardiovascular and respiratory causes are the most frequent.
3. Outcomes of cardiac arrests in the OR or PACU are superior to outcomes for in-hospital arrests due to causes not related to anesthesia.
4. Even though all anesthesiologists are very familiar with PALS guidelines and can work together well, it is just as important in resuscitations that the event manager role be specifically assigned as quickly as possible.
PEDIATRIC CARDIAC ARREST DURING ANESTHESIA
Most anesthetics provided by pediatric anesthesiologists end satisfactorily, if not happily. Despite this generally optimistic view of pediatric anesthesiology, “this is a serious business we are in.” (Keon, personal communication, 1985) Cardiac arrests do occur during the conduct of anesthesia in children, although data is incomplete regarding the precise incidence of anesthesia-related cardiac arrest in children. Before examination of incidence, etiology, and management of these anesthesia-related cardiac arrests, it is important to remember that many of these arrests are not due to poor or inadequate anesthetic care but rather result from either the critical condition of the patients or complications of the surgical procedure.
INCIDENCE
CLINICAL PEARL Incidence of anesthesia-related cardiac arrest of all pediatric groups is 1.8:10,000.
The Pediatric Perioperative Cardiac Arrest (POCA) Registry was formed in 1994 with the intention of elucidating the incidence, clinical factors, and outcomes associated with cardiac arrest in anesthetized children. With the information obtained about the etiology of anesthesia-related cardiac arrest in children, further goals of the POCA registry were to identify strategies that might possibly decrease the incidence of these arrests. The registry relies on voluntary enrollment and reporting by institutions that have agreed to participate in data collection. Information collected includes the type of institution, the number and training of anesthesia providers, and number and types of cases. A standardized data form for all cases of cardiac arrest was used. Cardiac arrest was defined as either the need for chest compression or as death. Patients from birth to 18 years were included. Data on the incidence of anesthesia-related cardiac arrest for neonates as a separate group is not available.
1. Infants: Incidence of anesthesia-related cardiac arrest is 15:10,000 with a range of 9.2 to 19:10,000.
2. Children: Incidence of anesthesia-related cardiac arrest is 3.3:10,000 with a range of 0 to 4.3:10,000.
3. All pediatric groups: Incidence of anesthesia-related cardiac arrest is 1.8:10,000 (1).
a. Although it is well documented that higher American Society of Anesthesiologists (ASA) Physical Status with or without emergency status correlates with a higher incidence of cardiac arrest, pediatric data using this classification are not available.
b. In pediatrics, the presence of congenital heart disease and other congenital anomalies was also correlated with a higher incidence of cardiac arrest.
ETIOLOGIES
CLINICAL PEARL The most common etiologies of pediatric cardiac arrest include cardiovascular and medication-related causes. The most frequent cardiovascular causes include intravascular volume depletion and the consequences of massive transfusions. Intravascular injection of local anesthetics, opioid induced respiratory depression, or residual neuromuscular blockade account for the most common lethal medication errors. Laryngospasm is the most common respiratory event.
There are a variety of etiologies relating to pediatric cardiac arrest during anesthesia. Cardiovascular and medication-related causes remain the most common.
1. One hundred and fifty anesthesia-related cardiac arrests from 1994 to 1997 were analyzed. More than 50% of arrests occurred among infants. Medications accounted for 37% of all arrests. The most common medication cause was cardiovascular depression due to inhalational agents. During this reporting period, it is likely that halothane was the offending agent in many of these cases. However, it is important to remember that sevoflurane, now a more commonly used agent, is also a cardiac depressant and arrests related to its effects continue to be reported.
2. Other medication-related causes included syringe swaps and succinylcholine-induced hyperkalemia.
3. In a follow-up period between 1998 and 2004, the registry analyzed more than 300 perioperative cardiac arrests (2,3). One hundred and ninety-three were related to anesthetic causes. The percentage of arrests related to medications decreased from 37% reported during the 1994-to-1997 period to 18%. This decrease is largely due to fewer cases of cardiovascular depression secondary to decreased halothane inhalational agents and less use of succinylcholine. Cardiovascular causes accounted for a slightly larger portion of the total, however, increasing from 32% of the total to 41% (see Table 35.1).
These larger categories can be further subdivided as follows:
1. For the cardiovascular causes, intravascular volume depletion or the results of massive transfusion were the most frequently cited etiology.
a. Hypovolemia was often due to bleeding. The most common anesthesia-related factors were underestimation of blood loss, inadequate peripheral intravenous (IV) access, and absence or lack of transduction of central venous catheter.
b. Additional causes of cardiac arrest such as hyperkalemia or hypocalcemia were related to massive transfusion.
c. Other cardiovascular causes for cardiac arrest were hypoglycemia, anaphylaxis, embolism of air or clot, sepsis, or excessive vagal responses.
TABLE 35.1 Pediatric Perioperative Cardiac Arrest (POCA) registry reported etiologies for anesthesia-related cardiac arrest
Primary cause | 1994–1997 (n = 150) | 1998–2004 (n = 193) |
Cardiovascular | 32% | 41% |
Medication | 37% | 18% |
Respiratory | 20% | 27% |
Equipment | 7% | 5% |
Morray JP, Geiduschek JM, Ramamoorthy C, et al. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) registry. Anesthesiology. 2000;93:6–14; Morray JP, Posner K. Pediatric perioperative cardiac arrest: in search of definition(s). Anesthesiology. 2007;106: 207–208.
2. Medication-related causes for cardiac arrest included inadvertent intravascular injection of local anesthetic, opioid-induced respiratory depression, or residual neuromuscular blockade.
3. Respiratory events accounted for a higher percentage (27%) in the more recent analysis. Laryngospasm was the most common respiratory event.
a. Other causes cited were inadequate oxygenation, accidental extubation, bronchospasm, and difficult intubation.
4. Equipment failure was also reported as a cause of cardiac arrest, although this category accounted for only 5% of cases.
a. Problems secondary to central venous line (CVL) placement such as pneumothorax, hemothorax, or cardiac tamponade accounted for most arrests in this category.
The POCA registry was most recently analyzed for anesthesia-related cardiac arrests in children with heart disease. One hundred and twenty-seven anesthesia-related cardiac arrests in children with heart disease were reported to the POCA Registry from 1994 to 2005. These children had higher ASA scores and were more likely to arrest from cardiovascular causes. They also had a higher mortality rate compared to children without heart disease. Patients with a single ventricle, aortic stenosis, or cardiomyopathy were reported most often (4).
OUTCOMES
CLINICAL PEARL The outcome for children following anesthesia-related cardiac arrest is much better than for in-hospital non-anesthesia-related arrests with regard to survival and neurologic deficits.
The outcomes from these anesthesia-related cardiac arrests can be assessed using a variety of measures. Return of spontaneous circulation (ROSC), survival, and survival to hospital discharge have all been used as outcome indicators.
1. The outcome for children following anesthesia-related cardiac arrest is much better than for in-hospital non–anesthesia-related arrests with regard to survival and the development of new neurologic deficits.
a. Many children who have in-hospital, non–anesthesia-related arrests do not survive and among those who do, some have new neurologic deficits.
b. Overall, 92% of anesthesia-related cardiac arrests are resuscitated to ROSC, 68% survive to hospital discharge, and 57% return to their baseline neurologic status (2,3).
c. As a comparison, following in-hospital cardiac arrest, 51% of children have ROSC, 28% survive to hospital discharge, and only 22% return to their baseline neurologic status (5–7).
MANAGEMENT
CLINICAL PEARL The initial resuscitation of pediatric cardiac arrest starts with managing the circulation ©, airway (A), and breathing (B), formerly known as A,B,Cs.
Proper monitoring of ventilation and oxygen delivery is paramount.
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