Pediatric Perioperative Life Support

Intraoperative Cardiac Arrest: Immediate Treatment and Diagnostic Evaluation

Although perioperative cardiac arrest during anesthetic care in infants and children is a rare event, its consequences can be devastating. Risk factors associated with perioperative cardiac arrest include cardiac surgery, younger age, presence of comorbid conditions and emergency surgery. Although medication-related etiologies formerly predominated, the elimination of halothane from anesthetic care has resulted in a shift in etiology to hemodynamic events related to blood loss or hyperkalemia associated with the rapid administration of blood products. Rarely, cardiac arrest can be sudden and unexpected without an obvious pre-existing etiology in an otherwise apparently healthy patient. We present a 16-month-old child who experienced a sudden cardiac arrest following anesthetic induction for a routine urologic procedure. The potential etiology of cardiac arrest during anesthesia is reviewed, keys to resuscitation discussed, and an outline for the investigative work-up presented.

The use of pressure-controlled mechanical ventilation in a swine model of intraoperative pediatric cardiac arrest

BACKGROUND

Current pediatric resuscitation guidelines suggest that resuscitators using an advanced airway deliver 8-10 breaths per minute while carefully avoiding excessive ventilation. In the intraoperative setting, having a dedicated ventilation rescuer may be difficult because of limited personnel. Continuing pressure-controlled mechanical ventilation during resuscitation for intraoperative cardiac arrest reduces personnel needed and the risk of hyperventilation but might risk hypoventilation during chest compression delivery.

AIMS

To determine whether the use of pressure-controlled mechanical ventilation at prearrest settings provides normoxia and normocarbia during resuscitation from cardiac arrest.

METHODS

We retrospectively analyzed combined data from preclinical randomized controlled trials. Two-week-old swine (3-4 kg) underwent asphyxia-induced cardiac arrest. Animals were resuscitated with periods of basic and advanced life support. During resuscitation, pressure-controlled mechanical ventilation was delivered at the prearrest respiratory rate, peak inspiratory pressure, and positive end-expiratory pressure. Arterial blood gases were measured prearrest, at 11 minutes of asphyxia, and at 8 and 20 minutes of cardiopulmonary resuscitation.

RESULTS

Piglets (n = 154) received pressure-controlled mechanical ventilation before and during cardiopulmonary resuscitation with a peak inspiratory pressure of 14-15 cm H₂ O, positive end-expiratory pressure of 4 cm H₂ O, 20 breaths/minute, and an inspiratory:expiratory ratio of 1:2. During asphyxia, the arterial blood gas showed the expected severe hypercarbia and hypoxia. Continuing pressure-controlled mechanical ventilation using prearrest parameters and increasing the FiO₂ to 1.0 returned the PaCO₂ to prearrest levels and slightly increased the partial pressure of arterial oxygen at 8 and 20 minutes of cardiopulmonary resuscitation.

CONCLUSION

In this piglet model of resuscitation from asphyxial arrest, pressure-controlled mechanical ventilation during cardiopulmonary resuscitation at the prearrest ventilator settings with an FiO₂ of 1.0 provides adequate oxygenation and restores normocarbia. Clinical investigation is warranted to determine the benefits of continuing pressure-controlled mechanical ventilation at prearrest parameters during pediatric cardiopulmonary resuscitation.

Operating Room Crisis Checklists and Emergency Manuals

Crisis checklists and emergency manuals are cognitive aids that help team performance and adherence to evidence-based practices during operating room crises. Resources to enable local implementation and training (key for effective use) are linked at http://www.emergencymanuals.org.

Supplemental Digital Content is available in the text.

Assessment Tools for Use During Anesthesia-Centric Pediatric Advanced Life Support Training and Evaluation

BACKGROUND

Pediatric perioperative cardiac arrests are rare events that require rapid, skilled and coordinated efforts to optimize outcomes. We developed an assessment tool for assessing clinician performance during perioperative critical events termed Anesthesia-centric Pediatric Advanced Life Support (A-PALS). Here, we describe the development and evaluation of the A-PALS scoring instrument.

METHODS

A group of raters scored videos of a perioperative team managing simulated events representing a range of scenarios and competency. We assessed agreement with the reference standard grading, as well as interrater and intrarater reliability.

RESULTS

Overall, raters agreed with the reference standard 86.2% of the time. Rater scores concerning scenarios that depicted highly competent performance correlated better with the reference standard than scores from scenarios that depicted low clinical competence (P < 0.0001). Agreement with the reference standard was significantly (P < 0.0001) associated with scenario type, item category, level of competency displayed in the scenario, correct versus incorrect actions and whether the action was performed versus not performed. Kappa values were significantly (P < 0.0001) higher for highly competent performances as compared to lesser competent performances (good: mean = 0.83 [standard deviation = 0.07] versus poor: mean = 0.61 [standard deviation = 0.14]). The intraclass correlation coefficient (interrater reliability) was 0.97 for the raters' composite scores on correct actions and 0.98 for their composite scores on incorrect actions.

CONCLUSIONS

This study provides evidence for the validity of the A-PALS scoring instrument and demonstrates that the scoring instrument can provide reliable scores, although clinician performance affects reliability.