Cardiac arrest in the OR
                                   Cardiac Arrest in the
                                        ...
POCA Registry Data                                                                          POCA Registry Data
           ...
Smith, H. M. et al.
                                          Anesth Analg 2008:106, 1062




        Airway Obstruction  ...
Laryngospasm
     Why are children at ↑ risk?
       • Difficult to apply tight-fitting mask
       • ↑ minute oxygen requ...
Cardiac arrest in the OR
Halothane                                            Sevoflurane                  Inhaled agents:...
Cardiac Resuscitation                                                  Bupivacaine Toxicity
    For bupivacaine toxicity: ...
Cardiac arrest in the OR                            Cardiac arrest in the OR
Succinylcholine:
  • Fastest onset/offset rel...
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Cardiac Arrest in the Pediatric OR

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Cardiac Arrest in the Pediatric OR

  1. 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 Children’s Hospital of Buffalo • Differential diagnosis: SUNY at Buffalo, • Identify most probable diagnosis, specific And University of Rochester, intervention Rochester, NY • Use “lateral thinking”: consider alternate diagnoses… 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 ≥3 & Emergency Rackow • Main causes: 56% resp, 33% CV 5 Graff • Mortality: Smith Cohen • ASA 1/2, 1.2/10,000 Keenan Smith • ASA ≥3, 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 1
  2. 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: • ⇑K+ 2 o to massive Tx of old blood • 22% no CVP or not transduced • ASA P/S ≥ 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% • ↓ 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 brief…or not Bradycardia is bad! • Establish adequate IV access…for site of Sx! • Fluid = CO x SVR ⇓ BP Rx: • 20-30 ml/kgfn {ANS, humoral} SVR is a loading Give volume ive volume, ⇑dP/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 α volume status • Caused by rapid direct infusion of old • Older child – systolic pressure, CVP, UO, capnogram blood in infants • Use isotonic clear fluids to resuscitate… • 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. 3. Smith, H. M. et al. Anesth Analg 2008:106, 1062 Airway Obstruction Laryngospasm Issues to panic over: • I’m losing the airway! • NO iv access yet! • Isn’t 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 inlet—vocal cord • ⇑ incidence In infants & young children irritation due to foreign substance, light • ⇑ incidence in children with recent URI anaesthesia • ⇑ incidence 5x with passive smoking • Jones DT et al. Otolaryngol Head Neck Surg 2006:135;12 • ⇑ effort to inspire… ⇑ negative intrathoracic • ⇑ incidence GERD, secretions, blood pressure…false vocal cords involute…closed • ⇑ incidence with UA disease (T&A) glottis…hypoxia (N2O) • ⇑ with light anesthesia • Schwartz D, et al. Ped Anesth 2004:14;820 • Hypoxia ⇒ bradycardia ⇒ cardiac arrest 3
  4. 4. Laryngospasm Why are children at ↑ risk? • Difficult to apply tight-fitting mask • ↑ minute oxygen requirement • ↓ FRC…oxygen reserve • preterm < neonate < infant < child < adult • Especially if had been crying…atelectasis • 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 ⇒ Sevoflurane < 60/min adolescents • Local anaesthetic toxicity • Slow HR = Low cardiac output in infants • Succinylcholine…hyperkalemia • Most important is to AVOID this situation • Rx: oxygen and atropine 20 µg/kg IV/IM • Miscellaneous drugs: • If asystole occurs, do NOT waste time giving • Clonidine, 5-HT3 atropine…this is not a vagal response. Give • Drug swap/overdose: EPINEPHRINE 10 µg/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 ⇓ CI, HR, more hypotension and negative inotropic effects • Halothane assoc'd with more hypotension and more pressors during emergence 4
  5. 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 = concentration…25-35%! 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, BP… • EF better than halothane • Fewer arrhythmias • better for CHD • Establish adequate IV access • Maintain normovolemia • Avoid rapid Tx old blood…check 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 5
  6. 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 • …CPR, 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 ⇒ 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 • ⇑ K+ may be extremely resistant to treatment: anaesthesia • Ca2+ restores the gradient between the resting and • Assoc’d 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. 6
  7. 7. Cardiac arrest in the OR Cardiac arrest in the OR Succinylcholine: • Fastest onset/offset relaxant Outcome of arrests: • Sevoflurane inductions… • Institute definitive treatment…restore • 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 reversible…ecg reverts prognosis diminishes • Repeat doses of Calcium may be required A Happy Outcome 7

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