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Cardiac Arrest in the Pediatric OR
1. Cardiac arrest in the OR
Cardiac Arrest in the
Immediate response:
Pediatric OR ⢠Call for help!!!! 911?
⢠Stop anaesthetic/ventilate with 100% oxygen
Jerrold Lerman BASc, MD, FRCPC, FANZCA ⢠CPR
Clinical Professor of Anesthesiology
Women and Childrenâs Hospital of Buffalo
⢠Differential diagnosis:
SUNY at Buffalo, ⢠Identify most probable diagnosis, specific
And University of Rochester, intervention
Rochester, NY
⢠Use âlateral thinkingâ: consider alternate
diagnosesâŚ
Perioperative Mortality
20 in children Cardiac Arrest
Mortality per 10,000 Anesthetics
Demographics:
Anesthesia-Related
15 Beecher
⢠India: 2003-08, non-CVS, ophthalmol
Clifton
⢠CA rate: 27/12,158 (1/3 due to anesthesia)
10 ⢠Risk factors: < 1 yr, ASA âĽ3 & Emergency
Rackow ⢠Main causes: 56% resp, 33% CV
5
Graff ⢠Mortality:
Smith Cohen ⢠ASA 1/2, 1.2/10,000
Keenan
Smith ⢠ASA âĽ3, 7.7/10,000
Tiret Morray
Petruscak Romano Patel
0
1950 1960 1970 1980 1990 2000
Year Morray JP
Bharti N, et al
Eur J Anaesth 2009: Mar 18 epub
Anesthesiology Clinics N Am 2002;20:1-28
Cardiac Arrest POCA Registry Arrests
Demographics:
⢠1988-2005: 92,881 anesthetics <18 yr
⢠2.9 CA/10,000 non-cardiac Sx vs. 127/10,000 cardiac
Sx
⢠0.65/10,000 CA due to anesthesia
⢠CA incidence and death was greatest in neonates
during CV Sx
⢠88% of CA had CHD
Flick RJ, et al Bhananker SM et al.
Anesthesiology 2007:106;207
Anesth Analg 2007:344
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2. POCA Registry Data POCA Registry Data
Factors in 1998-03: Spinal fusion 8/1048% underestimated
⢠cases of electrolyte
Mortality factors: ⢠36% due to CVS causes Cranie
Imbalance, due to K+
blood loss
overdose from old blood
⢠22% inadequate
⢠193 CA reported between 1998 & 2004 ⢠Hypovolemia IV access
⢠Multivariate analysis: ⢠âK+ 2 o to massive Tx of old blood ⢠22% no CVP or not
transduced
⢠ASA P/S ⼠3: OR 4.4 compared with ASA <3 ⢠27% due to Resp causes
⢠Emergency surgery: OR 3.3 compared with non-emergency ⢠laryngospasm, airway obstruction, inadequate O2, early
⢠(from 1994-2004, almost 50% of CA were <1 yr) extubation 9 Halothane, 6 Sevo
3 Succ
⢠Anesthetic period: ⢠20% due to Medication 2 Neostigmine
⢠Pre-induction and induction 24% ⢠â by 50%
⢠Maintenance 58% ⢠Halothane, Sevoflurane, Succ
⢠Emergence, transport & recovery 19% ⢠4% due to Equipment
⢠CVP line insertion and sequelae
Bhananker SM, et al. Bhananker SM, et al.
Anesth Analg 2007:105, 344 Anesth Analg 2007:105, 344
Cardiac arrest
Hypovolemia/hypotension:
Tachycardia is good,
⢠Preoperative fasting interval is briefâŚor not
Bradycardia is bad!
⢠Establish adequate IV accessâŚfor site of Sx!
⢠Fluid = CO x SVR
â BP Rx:
⢠20-30 ml/kgfn {ANS, humoral}
SVR is a loading
Give volume ive volume,
âdP/dt
⢠Replace losses 3x blood volume
CO = HR x SV
⢠PRBC 4isml/kg/Gm Hb
SV a fn {preload, afterload, dP/dt}
Cardiac arrest Cardiac arrest
Fluid resuscitation:
⢠Intraoperative blood loss must be carefully Hyperkalemia:
assessed:
⢠Neonate -- systolic pressure ι volume status ⢠Caused by rapid direct infusion of old
⢠Older child â systolic pressure, CVP, UO, capnogram
blood in infants
⢠Use isotonic clear fluids to resuscitateâŚ
⢠AVOID hyponatremic solutions! ⢠Treatment requires immediate treatment
⢠10-20 ml/kg rapidly with iv Calcium chloride 10 mg/kg (or
⢠Caution above 100 ml/kg
Calcium gluconate 30 mg/kg) repeatedly
⢠When blood loss is excessive (what is that?):
⢠colloid, blood products (PRBC 4 ml/kg gm Hb) until the arrhythmias resolved
⢠IV site (not through CVP)
⢠Temperature
⢠Calcium
2
3. Smith, H. M. et al.
Anesth Analg 2008:106, 1062
Airway Obstruction Laryngospasm
Issues to panic over:
⢠Iâm losing the airway!
⢠NO iv access yet!
⢠Isnât there anyone younger in the department to do
these cases?
⢠Differential diagnosis:
⢠Oropharyngeal obstruction
⢠Glottic (laryngeal) obstruction
⢠Tracheo/bronchial obstruction
⢠Central apnea
Cardiac Arrest in the OR Laryngospasm
Laryngospasm: Predisposed with:
⢠Closure of the glottic inletâvocal cord ⢠â incidence In infants & young children
irritation due to foreign substance, light ⢠â incidence in children with recent URI
anaesthesia ⢠â incidence 5x with passive smoking
⢠Jones DT et al. Otolaryngol Head Neck Surg 2006:135;12
⢠â effort to inspire⌠â negative intrathoracic ⢠â incidence GERD, secretions, blood
pressureâŚfalse vocal cords involuteâŚclosed ⢠â incidence with UA disease (T&A)
glottisâŚhypoxia (N2O) ⢠â with light anesthesia
⢠Schwartz D, et al. Ped Anesth 2004:14;820
⢠Hypoxia â bradycardia â cardiac arrest
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4. Laryngospasm
Why are children at â risk?
⢠Difficult to apply tight-fitting mask
⢠â minute oxygen requirement
⢠â FRCâŚoxygen reserve
⢠preterm < neonate < infant < child < adult
⢠Especially if had been cryingâŚatelectasis
⢠N2O rapidly comes out of blood
⢠Rapidly dilutes oxygen in alveolus
Pediatr Anesth 2008:18;303
Cardiac Arrest Cardiac arrest
Bradycardia: Medications:
⢠Definition: < 100/min infants, < 80/min children, ⢠Anesthetics: Halothane â Sevoflurane
< 60/min adolescents
⢠Local anaesthetic toxicity
⢠Slow HR = Low cardiac output in infants
⢠SuccinylcholineâŚhyperkalemia
⢠Most important is to AVOID this situation
⢠Rx: oxygen and atropine 20 ¾g/kg IV/IM ⢠Miscellaneous drugs:
⢠If asystole occurs, do NOT waste time giving ⢠Clonidine, 5-HT3
atropineâŚthis is not a vagal response. Give ⢠Drug swap/overdose:
EPINEPHRINE 10 ¾g/kg iv immediately with CPR ⢠Esmolol, lidocaine
Inhaled Agents
In comparison to Sevoflurane:
⢠Halothane causes more hypotension
⢠Halothane causes more arrhythmias
⢠In children with CHD, two studies:
⢠Halothane caused â CI, HR, more hypotension
and negative inotropic effects
⢠Halothane assoc'd with more hypotension and
more pressors during emergence
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5. Cardiac arrest in the OR
Halothane Sevoflurane Inhaled agents:
Max = 5% Max = 8%
FA /FI = 0.35 FA /FI = 0.5
⢠Overfilled vaporizer
FA /FI (child) = 0.5 FA /FI (child) = 0.5 ⢠Max deliverable
MAC equiv = MAC equiv = concentrationâŚ25-35%!
2.5%/1.1 or 4%/2.5 or
2.3 MAC 1.6 MAC
⢠In the first few minutes,
8-25% ET concentration
⢠Spontaneous ventilation
prevents an overdose!
Yasuda N, et al Yasuda, et al
Anesth Analg 1991:72;484 ovc.uoguelph.ca
Anesth Analg 1991
Halothane in Dogs Avoiding the Oops Factor
Strategies:
⢠Switch from Halothane to Sevoflurane:
⢠95% of recent SPA members have switched
⢠Sevo maintains HR, BPâŚ
⢠EF better than halothane
⢠Fewer arrhythmias
⢠better for CHD
⢠Establish adequate IV access
⢠Maintain normovolemia
⢠Avoid rapid Tx old bloodâŚcheck K conc.
Gibbons RT, et al
Anesth Analg 1977:56;32
Intravascular injections Cardiac arrest in the OR
ECG changes after bupivacaine with
epinephrine:
⢠ST and T-wave changes
⢠Tachycardia is unreliable!
so watch the ecg continuously!
Fisher et al, CJA 44:592, 1997
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6. Cardiac Resuscitation Bupivacaine Toxicity
For bupivacaine toxicity: Lipid Regimen:
⢠Bretylium -- withdrawn ⢠Based on animal data primarily
⢠20% Intralipid 1 ml/kg every 3 minutes up
⢠Epinephrine?
to 3 ml/kg
⢠âŚCPR, time, prayers
⢠Intralipid infusion 0.25 ml/kg/min
⢠Maximum expected total volume expected
⢠SURENDIPITY! is 8 ml/kg
Bupi Resuscitation in Rats Malignant Hyperthermia?
Case:
⢠3 year old male, RIH
⢠Healthy, motor dev?
⢠IV or inhaled induction, then
Succinylcholine
12.5 mg/kg
18 mg/kg
LD50 ⢠Within 60 seconds, peaked T waves, V
Tach â to V Fib
Weinberg GL, et al.
Anesthesiology 1998:88;1071
Hyperkalemia Hyperkalemia
Intervention:
Scenario: ⢠CPR resuscitation algorithm is NOT
⢠Sudden onset of v. fib/cardiac arrest in a appropriate for these arrests!
healthy child during induction of ⢠â K+ may be extremely resistant to treatment:
anaesthesia
⢠Ca2+ restores the gradient between the resting and
⢠Assocâd with the use of succinylcholine, threshold membrane potentials, no effect on K+
worsened with halothane level!
⢠This is NOT Malignant Hyperthermia! ⢠Calcium chloride 10 mg/kg or Calcium Gluconate
30 mg/kg
⢠Occurs in patients with myopathies (males,
⢠Massive doses of Ca2+ may be required to restore
DMD), UMNL, LMNL, prolonged sepsis, NSR
burns (>7% SA)
⢠There is NO place for Dantrolene in these
patients.
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7. Cardiac arrest in the OR Cardiac arrest in the OR
Succinylcholine:
⢠Fastest onset/offset relaxant Outcome of arrests:
⢠Sevoflurane inductions⌠⢠Institute definitive treatmentâŚrestore
⢠Hyperkalemia after sux usually in young males circulation and prognosis excellent
⢠Sudden onset V. Fib/Tach
⢠As the number of failing organ systems
⢠Definitive Rx: iv Calcium chloride 10mg/kg
increase, the prognosis diminishes
(Ca gluconate 30 mg/kg)
⢠CPR to promote circulation of blood AND Ca2+ ⢠As the duration of arrest increases,
⢠Immediately reversibleâŚecg reverts
prognosis diminishes
⢠Repeat doses of Calcium may be required
A Happy Outcome
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