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:

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.

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