Intraoperative Cardiac Arrest

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 for Intraoperative Pulseless Arrest:

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

Important Notes:

• 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 rhythm: 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)

Methods of Measuring Effectiveness of CPR

• ETCO2 levels >10 mm Hg are associated with higher likelihood of ROSC
  • >30mmHg:  good
  • <10 mmHg: bad
• Diastolic pressure on a-line (relaxation right atrial pressure):
  • >20 mmHg infants
  • >30 mmHg children
  • <15 mmHg - bad (in adults associated with no ROSC during CPR)
• MVO2
  • <30% was associated with no ROSC

Post Resuscitation:

• Avoid hypotension
• Allow to be cool (avoid hyperthermia)
• Avoid hypoglycemia
• Avoid hyperventilation (unless herniating)

Critical Event Resources:

PEDI CRISIS APP

Available on Apple Store and Google Play

https://pedsanesthesia.org/pedi-crisis-app/

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