Pediatric Perioperative Cardiac Arrest, Death in the Off Hours: A Report From Wake Up Safe, The Pediatric Quality Improvement Initiative.

BACKGROUND: Pediatric perioperative cardiac arrest (CA) is a rare but catastrophic event. This case-control study aims to analyze the causes, incidence, and outcomes of all pediatric CA reported to Wake Up Safe. Factors associated with CA and mortality after arrest are examined and possible strategies for improving outcomes are considered. METHODS: CA in children was identified from the Wake Up Safe Pediatric Anesthesia Quality Improvement Initiative, a multicenter registry of adverse events in pediatric anesthesia. Incidence, demographics, underlying conditions, causes of CA, and outcomes were extracted. Descriptive statistics and logistic regression were used to study the above factors associated with CA and mortality after CA. RESULTS: A total of 531 cases of CA occurred during 1,006,685 anesthetics. CA was associated with age (odds ratio [95% confidence interval] comparing ≥6 vs <6 months of 0.26 [0.22-0.32]; P = .014), American Society of Anesthesiologists physical status (ASA PS III-V versus I-II, 9.24, 7.23-11.8; P < .001), and emergency status (3.55, 2.88-4.37; P < .001). Higher ASA PS was associated with increased mortality (ASA PS III-V versus I-II, 3.25, 1.20-8.81; P = .02) but anesthesia-related arrests were correlated with lower mortality (0.44, 0.26-0.74; P = .002). ASA emergency status (1.83, 1.05-3.19; P = .03) and off hours (night and weekend versus weekday, 2.17, 1.22-3.86; P = .008) were other factors associated with mortality after CA. CONCLUSIONS: The Wake Up Safe data validate single-institution studies' findings regarding incidence, factors associated with arrest, and outcomes of pediatric perioperative CA. However, CA occurring during the off hours had significantly worse outcomes, independent of patient physical status or emergency surgery. This suggests an opportunity for improved outcomes.

Cardiac arrest in anesthetized children: recent advances and challenges for the future.

Over the past 50 years the incidence of anesthesia-related cardiac arrest has declined, despite increased patient co-morbidities, the most significant determinant of anesthetic risk. Multiple factors have contributed to this improvement including safer anesthetic agents, better monitoring devices and the development of a specialized pediatric environment. Provider skill has benefitted from improved training and recognition of high-risk situations. Further improvements will depend on international, multispecialty efforts to standardize terminology and analyze large numbers of these infrequent adverse events.

Anesthesia-related cardiac arrest in children with heart disease: data from the Pediatric Perioperative Cardiac Arrest (POCA) registry.

BACKGROUND: From 1994 to 2005, the Pediatric Perioperative Cardiac Arrest Registry collected data on 373 anesthesia-related cardiac arrests (CAs) in children, 34% of whom had congenital or acquired heart disease (HD). METHODS: Nearly 80 North American institutions that provide anesthesia for children voluntarily enrolled in the Pediatric Perioperative Cardiac Arrest Registry. A standardized data form for each perioperative CA in children 18 years old or younger was submitted anonymously. We analyzed causes of and outcomes from anesthesia-related CA in children with and without HD. RESULTS: Compared with the 245 children without HD, the 127 children with HD who arrested were sicker (92% vs 62% ASA physical status III-V; P < 0.01) and more likely to arrest from cardiovascular causes (50% vs 38%; P = 0.03), although often the exact cardiovascular cause of arrest could not be determined. Mortality was higher in patients with HD (33%) than those without HD (23%, P = 0.048) but did not differ when adjusted for ASA physical status classification. More than half (54%) of the CA in patients with HD were reported from the general operating room compared with 26% from the cardiac operating room and 17% from the catheterization laboratory. The most common category of HD lesion in patients suffering CA was single ventricle (n = 24). At the time of CA, most patients with congenital HD were either unrepaired (59%) or palliated (26%). Arrests in patients with aortic stenosis and cardiomyopathy were associated with the highest mortality rates (62% and 50%, respectively), although statistical comparison was precluded by small sample size for some HD lesions. CONCLUSIONS: Children with HD were sicker compared with those without HD at the time of anesthesia-related CA and had a higher mortality after arrest. These arrests were reported most frequently from the general operating room and were likely to be from cardiovascular causes. The identification of causes of and factors relating to anesthesia-related CA suggests possible strategies for prevention.

Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry.

BACKGROUND: The initial findings from the Pediatric Perioperative Cardiac Arrest (POCA) Registry (1994-1997) revealed that medication-related causes, often cardiovascular depression from halothane, were the most common. Changes in pediatric anesthesia practice may have altered the causes of cardiac arrest in anesthetized children. METHODS: Nearly 80 North American institutions that provide anesthesia for children voluntarily enrolled in the Pediatric Perioperative Cardiac Arrest Registry. A standardized data form for each perioperative cardiac arrest in children

Anesthesia-related cardiac arrest in children. An update.

The improvement in mortality rates for anesthetized children over the past 50 years reflects the many improvements that have been made in pediatric perioperative care. The modern pediatric anesthesiologist is better trained than the predecessors of half a century ago, and has a vastly improved arsenal of monitoring devices and anesthetic agents from which to choose. The modern pediatric perioperative environment is better equipped to meet the unique needs of children. Techniques practiced by surgeons, nurses, radiologists, and pharmacologists help create a far more sophisticated infrastructure than existed 50 years ago. Given these changes, it is not surprising that outcomes for patients have improved.