Intraoperative Cardiac Arrest: Difference between revisions

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Source: Shaffner DH, Heitmiller ES, Deshpande JK. Pediatric perioperative life support. Anesth Analg. 2013 Oct;117(4):960-979. doi: 10.1213/ANE.0b013e3182a1f3eb. Epub 2013 Sep 10. PMID: 24023023.
Source: Shaffner DH, Heitmiller ES, Deshpande JK. Pediatric perioperative life support. Anesth Analg. 2013 Oct;117(4):960-979. doi: 10.1213/ANE.0b013e3182a1f3eb. Epub 2013 Sep 10. PMID: 24023023.
[[File:PALS Shaffner.jpg|thumb]]
[[File:PALS Shaffner.jpg|thumb|Intraoperative Pulseless Arrest Resuscitation]]


* Medication have not been shown to change outcome, more emphasis on effective compression.
* Compression depth:
** For a child is at least ⅓ the depth of the chest size, or 5 cm
** For infant: 4cm
* Allow complete recoil, don’t lean on chest
* Don’t interrupt compression
* Intubate, follow ETCO2


* 100 compressions : 8-10 ventilations per min
* Avoid overinflation
* Biphasic shock  - First dose: 2-4J/kg  - Second dose: 4J/kg  - Third dose: 4-10J/kg
* Epi dose:  - 10 MICROg/kg IV/IO  - 100 MICROg/kg ETT
* PEA vs. VFib: PEA appears organized and pulseless
* Call for ECMO if no ROSC after 6 mins
* Ice to head
* If prone, perform 2 mins CPR prone, evaluate EtCO2 then consider supine
* IO access is as effective as IV access and may be easier to obtain during circulatory collapse
[[File:Prone Chest Compression.jpg|thumb|Prone Chest Compression (Shaffner et al. 2013)]]
'''<u>Critical Event Resources:</u>'''
App: PEDI-CRISIS
Available on Apple Store and Google Play


{{Stub Notice}}{{Stub Notice}}
{{Stub Notice}}{{Stub Notice}}

Revision as of 16:24, 18 November 2023

Incidence of Perioperative Cardiac Arrest (CA):

Increase with higher ASA status

Wake Up Safe Registry: 3.3 per 10,000 of arrest were anesthesia related. Aesthesia-related death was 0.36 per 10,000 anesthetics.

Pediatric Perioperative Cardiac Arrest (POCA) Registry: 1.4 +/- 0.45 per 10,000 were anesthesia related. Mortality rate: 26%

Children (<12 year old): 2x more likely to experience CA, infants (<1 year old): 10x, neonates (<1month old): 50x

Causes for Pediatric Perioperative Arrest:

  • CIRCULATORY FAILURE:
    • Hypovolemia: Hemorrhage, inadequate/inappropriate volume resuscitation/transfusion (patients < 24 months may not respond to hypotension with increase HR)
    • Hyperkalemia: Succinylcholine, TRANSFUSION (pRBC >2 weeks, speed of transfusion), reperfusion, myopathy, or renal insufficiency
    • Dysrhythmia: LA toxicity, line placement (safer to use Ultrasound guided vs. landmark technique)
    • Anaphylaxis
    • Venous Air Embolism
    • Malignant Hyperthermia: very rare
  • RESPIRATORY FAILURE:
    • Airway Obstruction: - Laryngospasm: Upper respiratory infection increases risk - Bronchospasm
    • Inadequate ventilation and oxygenation: difficult airway, mucus plug, kinked ETT, inadvertent extubation
    • Disordered control of breathing: drug overdose, neuromuscular diseases, apnea
    • Aspiration
  • SUDDEN CARDIAC COLLAPSE
    • Bradycardia or cardiovascular collapse: - Traction, pressure, or insufflation involving the abdomen, eye, neck, or heart - Undiagnosed cardiomyopathy
    • Overdose - Weight-based dosing of IV anesthetic on induction in a child with hypovolemia or compensated shock may lead to collapse

Important Resuscitation Steps:

  1. Inform team
  2. Stop surgical stimulation
  3. Stop anesthetics (gas & sedation gtt)  and vasodilatory meds
  4. 100% Oxygen
  5. Open fluids and Trendelenburg position
  6. Chest-compression
  7. Call for help
  8. Consider stopping potassium containing solutions (blood or hyperalimentation)
  9. Ask for ice to head
  10. Assign roles

Resuscitation Algorithm:

Source: Shaffner DH, Heitmiller ES, Deshpande JK. Pediatric perioperative life support. Anesth Analg. 2013 Oct;117(4):960-979. doi: 10.1213/ANE.0b013e3182a1f3eb. Epub 2013 Sep 10. PMID: 24023023.

Intraoperative Pulseless Arrest Resuscitation
  • Medication have not been shown to change outcome, more emphasis on effective compression.
  • Compression depth:
    • For a child is at least ⅓ the depth of the chest size, or 5 cm
    • For infant: 4cm
  • Allow complete recoil, don’t lean on chest
  • Don’t interrupt compression
  • Intubate, follow ETCO2
  • 100 compressions : 8-10 ventilations per min
  • Avoid overinflation
  • Biphasic shock - First dose: 2-4J/kg - Second dose: 4J/kg - Third dose: 4-10J/kg
  • Epi dose: - 10 MICROg/kg IV/IO - 100 MICROg/kg ETT
  • PEA vs. VFib: PEA appears organized and pulseless
  • Call for ECMO if no ROSC after 6 mins
  • Ice to head
  • If prone, perform 2 mins CPR prone, evaluate EtCO2 then consider supine
  • IO access is as effective as IV access and may be easier to obtain during circulatory collapse
Prone Chest Compression (Shaffner et al. 2013)


Critical Event Resources:

App: PEDI-CRISIS

Available on Apple Store and Google Play


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Go to the Generalized Suggested Outline for information on case-specific details for each page.

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