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:
- Inform team
- Stop surgical stimulation
- Stop anesthetics (gas & sedation gtt) and vasodilatory meds
- 100% Oxygen
- Open fluids and Trendelenburg position
- Chest-compression
- Call for help
- Consider stopping potassium containing solutions (blood or hyperalimentation)
- Ask for ice to head
- 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.
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
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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