Jeremy M. Geiduschek

Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry.

Background The Pediatric Perioperative Cardiac Arrest (POCA) Registry was formed in 1994 in an attempt to determine the clinical factors and outcomes associated with cardiac arrest in anesthetized children. Methods Institutions that provide anesthesia for children are voluntarily enrolled in the POCA Registry. A representative from each institution provides annual institutional demographic information and submits anonymously a standardized data form for each cardiac arrest (defined as the need for chest compressions or as death) in anesthetized children 18 yr of age or younger. Causes and factors associated with cardiac arrest are analyzed. Results In the first 4 yr of the POCA Registry, 63 institutions enrolled and submitted 289 cases of cardiac arrest. Of these, 150 arrests were judged to be related to anesthesia. Cardiac arrest related to anesthesia had an incidence of 1.4 ± 0.45 (mean ± SD) per 10,000 instances of anesthesia and a mortality rate of 26%. Medication-related (37%) and cardiovascular (32%) causes of cardiac arrest were most common, together accounting for 69% of all arrests. Cardiovascular depression from halothane, alone or in combination with other drugs, was responsible for two thirds of all medication-related arrests. Thirty-three percent of the patients were American Society of Anesthesiologists physical status 1–2; in this group, 64% of arrests were medication-related, compared with 23% in American Society of Anesthesiologists physical status 3–5 patients (P < 0.01). Infants younger than 1 yr of age accounted for 55% of all anesthesia-related arrests. Multivariate analysis demonstrated two predictors of mortality: American Society of Anesthesiologists physical status 3–5 (odds ratio, 12.99; 95% confidence interval, 2.9–57.7), and emergency status (odds ratio, 3.88; 95% confidence interval, 1.6–9.6). Conclusions Anesthesia-related cardiac arrest occurred most often in patients younger than 1 yr of age and in patients with severe underlying disease. Patients in the latter group, as well as patients having emergency surgery, were most likely to have a fatal outcome. The identification of medication-related problems as the most frequent cause of anesthesia-related cardiac arrest has important implications for preventive strategies.

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 ≤18 yr of age was submitted anonymously. We analyzed causes of anesthesia-related cardiac arrests and related factors in 1998–2004. RESULTS:From 1998 to 2004, 193 arrests (49%) were related to anesthesia. Medication-related arrests accounted for 18% of all arrests, compared with 37% from 1994 to 1997 (P < 0.05). Cardiovascular causes of cardiac arrest were the most common (41% of all arrests), with hypovolemia from blood loss and hyperkalemia from transfusion of stored blood the most common identifiable cardiovascular causes. Among respiratory causes of arrest (27%), airway obstruction from laryngospasm was the most common cause. Vascular injury incurred during placement of central venous catheters was the most common equipment-related cause of arrest. The cause of arrest varied by phase of anesthesia care (P < 0.01). Cardiovascular and respiratory causes occurred most commonly in the surgical and postsurgical phases, respectively. CONCLUSIONS:A reduction in the proportion of arrests related to cardiovascular depression due to halothane may be related to the declining use of halothane in pediatric anesthetic practice. The incidence of the most common remaining causes of arrest in each category may be reduced through preventive measures.

A Comparison of Pediatric and Adult Anesthesia Closed Malpractice Claims

BackgroundSince 1985, the Committee on Professional Liability of the American Society of Anesthesiologists has evaluated closed anesthesia malpractice claims. This study compared pediatric and adult closed claims with respect to the mechanisms of injury, outcome, the costs, and the role of care judged to be substandard. MethodsUsing a standardized form and method developed for analysis of closed claims, the American Society of Anesthesiologists Closed Claims Data Base was used to compare pediatric with adult anesthesia-related adverse events. ResultsOf the 2,400 total claims, 238 (1096) were in the pediatric age group (15 yr of age or younger). The pediatric claims presented a different distribution of damaging events compared with that of adults. In particular, respiratory events were more common among pediatric claims (43% versus 30% in adult claims; P ≤. 0.01). The mortality rate was greater in the pediatric claims (50% versus35% in adult claims; P≤ 0.01), anesthetic care more often was judged less than appropriate (54% versus 44% in adult claims; P ≤ 0.01), the complications more frequently were thought to be preventable with better monitoring (45% versus 30% in adult claims; P≤ 0.01), and the distribution of payments to the plaintiff was different (median payment,

The effect of chin lift, jaw thrust, and continuous positive airway pressure on the size of the glottic opening and on stridor score in anesthetized, spontaneously breathing children.

111,234 versus

The effects of common airway maneuvers on airway pressure and flow in children undergoing adenoidectomies.

90,000 in adult claims; P ≤ 0.05). Many of the differences between pediatric and adult claims were explained by a higher prevalence of patient injury caused by inadequate ventilation in the pediatric claims (20% versus 9% in adult claims; P ≤ 0.01). In pediatric compared with adult inadequate ventilation claims, poor medical condition and/ or obesity (6% versus 41%; P ≤ 0.01) were uncommon associated factors. Cyanosis (49%) and/or bradycardia (64%) often preceded cardiac arrest in pediatric claims related to inadequate ventilation, resulting in death (70%) or brain damage (30%) in previously healthy children. Although clinical clues suggested hypoxemia as a common mechanism of injury, the files did not contain enough information to explain the genesis of hypoxemia in these claims. ConclusionsComparison of adult and pediatric closed claims revealed a large prevalence of respiratory related damaging events—most frequently related to inadequate ventilation. In the opinion of the reviewers, 89% of the pediatric claims related to inadequate ventilation could have been prevented with pulse oxlmetry and/or end tidal CO2 measurement. However, pulse oximetry appeared to prevent poor outcome in only one of seven claims in which pulse oximetry was used and could possibly have done so.

Pain management for children following selective dorsal rhizotomy.

Chin lift and jaw thrust are two common maneuvers used to improve the patency of the upper airway during general anesthesia. We investigated the effect of these maneuvers combined with continuous positive airway pressure (CPAP) on the size of glottic opening and on stridor score. Forty children, aged 2–9 yr, premedicated with midazolam and spontaneously breathing end-tidal 1% halothane and equal parts of nitrous oxide and oxygen, were studied. A flexible fiberoptic bronchoscope was placed via mask and one nostril to the level of the junction of the soft palate and oropharynx. Video recordings and simultaneous stridor scores were obtained during six conditions: 1) chin unsupported, 2) manual chin lift, 3) chin lift and CPAP 10 cm H2O, 4) repeat chin unsupported, 5) manual jaw thrust, and 6) jaw thrust and CPAP 10 cm H2O. Videos were analyzed to determine the percentage of glottic opening (POGO) score. POGO score increased (P < 0.05) in Conditions 2, 3, 5, and 6. With increasing POGO score there was a decrease in stridor score (P < 0.05).

Epidural and intravenous bolus morphine for postoperative analgesia in infants.

Obstruction of the upper airway occurs frequently in anesthetized, spontaneously breathing children, especially in those with adenoidal hyperplasia. To improve airway patency, maneuvers such as chin lift (CL), jaw thrust (JT), and continuous positive airway pressure (CPAP) are often used. In this study, we examined the comparative efficacy of these maneuvers in children scheduled to undergo adenoidectomy. Sixteen children aged 2–9 yr were anesthetized with sevoflurane. During spontaneous breathing, the flows and pressures in the mask (ma), oropharynx (op), and esophagus (es) were measured simultaneously, and maximal pressure differences during inspiration (&Dgr;P) were calculated. After baseline recording, CL and JT maneuvers were performed in random order without and with CPAP (5 cm H2O). The observed &Dgr;Pma − Pes of 12.3 ± 3.4 cm H2O at baseline decreased with all airway maneuvers (P < 0.05). This resulted from decreases of &Dgr;Pma − Pop (P < 0.05) and &Dgr;Pop − Pes (P < 0.05) in all interventions except CL, in which &Dgr;Pma − Pop remained similar. In contrast, significant improvements of minute ventilation and maximal inspiratory peak flow (P > 0.05) were observed only with JT (with and without CPAP). We conclude that CL may improve airway patency and ventilation, whereas JT with or without CPAP was the most effective maneuver to overcome airway obstruction in children with adenoidal hyperplasia.

Unexpected cardiac arrest among children during surgery: a North American registry to elucidate the incidence and causes of anesthesia related cardiac arrest

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure used for treating lower extremity spasticity in patients with cerebral palsy. The purpose of this paper is to present a review of our institution’s first three years’ experience with postoperative pain and spasticity management in patients who have undergone SDR. The medical records of the 55 patients who had an SDR during the study period were reviewed. The basis of postoperative analgesia was morphine, with the majority of patients receiving continuous morphine infusions (20–40 μg · kg−1 · hr−1(n = 49), 60 μg · kg−1 · hr−1 (n = 1)). Four patients used a patient-controlled delivery system. One patient had successful analgesia with epidural morphine. Ketorolac (1 mg · kg−1iv loading dose followed by 0.5 mg · kg−1 iv every six hr for 48 hr) was used as an adjunct to morphine in six patients. For management of postoperative muscle spasm, an intravenous benzodiazepine was used (diazepam 0.1 mg · kg−1 (n = 2), or midazolam infusion 10–30 μg · kg−1· hr−1 (n = 51)). All patients were cared for on a ward where nurses were familiar with the use of continuous opioid and benzodiazepine infusions. All patients received continuous cardiorespiratory monitoring as well as frequent nursing assessment. There were no episodes of postoperative apnoea or excessive sedation. We have found the use of continuous infusions of morphine and midazolam, along with adjunct ketorolac, to be effective in treating postoperative pain and muscle spasms following SDR.RésuméEn neurochirurgie, on traite la spasticité de l’infirmité motrice cérébrale par la rhizotomie dorsale sélective (RDS). Cet article revise nos trois premières années d’expérience avec le traitement de la douleur et de la spasticité postopératoires chez des patients qui ont subi une RDS. Nous avons relevé les dossiers de 55 patients. Dans la majorité des cas, on a utilisé la morphine en perfusion continue (20–40 μg · kg−1 · h−1 (n = 49), et 60 μg kg−1· h−1 (n = 1) comme analgésique postopératoire principal. Quatre patients se sont auto-administré la morphine. Un patient a reçu une analgésie épidurale continue à la morphine. Chez six patients, du kétorolac (dose initiale de 1 mg · kg−1 iv suivie de 0,5 mg · kg−1 à toutes les six h pour 48 h) a été ajouté à la morphine. Pour traiter la spasticité postopératoire, nous avons utilisé une benzodiazépine (diazépam 0.1 mg · kg−1, (n = 2) ou une perfusion de midazolam 10–30 μg · kg−1 · h−1 (n = 51)). Tous les patients ont été traité dans leur service par des infirmières familières avec les perfusions continues de morphiniques ou de midazolam. Tous les patients ont été monitorisés en continu et évalués fréquemment par le personnel infirmier qui n’a pas décelé d’apnée ou de dépression respiratoire. Nous avons trouvé que les perfusions continues de morphine et de midazolam avec l’ajout de kétorolac étaient efficaces pour traiter la douleur postopératoire et les spasmes musculaires après RDS.

Respiratory complications during anaesthesia in Apert syndrome

PurposeTo compare two doses of bolus epidural morphine with bolus iv morphine for postoperative pain after abdominal or genitourinary surgery in infants.MethodsEighteen infants were randomly assigned to bolus epidural morphine (0.025 mg · kg−1 or 0.050 mg · kg−1) or bolus iv morphine (0.050–0.150 mg · kg−1). Postoperative pain was assessed and analgesia provided, using a modified infant pain scale. Monitoring included continuous ECG, pulse oximetry, impedance and nasal thermistor pneumography. The CO2 response curves and serum morphine concentrations were measured postoperatively.ResultsPostoperative analgesia was provided within five minutes by all treatment methods. Epidural groups required fewer morphine doses (3.8 ± 0.8 for low dose [LE], 3.5 ± 0.8 for high dose epidural [HE] vs. 6.7 ± 1.6 for iv, P < 0.05) and less total morphine (0.11 ± 0.04 mg · kg−1 for LE, 0.16 ± 0.04 for HE vs 0.67 ± 0.34 for iv, P < 0.05) on POD1 Dose changes were necessary in all groups for satisfactory pain scores. Pruritus, apnoea, and haemoglobin desaturation occurred in all groups. CO2 response curve slopes, similar preoperatively (range 36–41 ml · min−1 · mmHg ETco2−1 · kg−1) were generally depressed (range, 16–27 ml · min−1 · mmHg ETco2−1 · kg−1) on POD1. Serum morphine concentrations, negligible in LE (<2 ng · ml−1), were similar in the HE and iv groups (peak 8.5 ± 12.5 and 8.6 ± 2.4 ng · ml−1, respectively).ConclusionEpidural and iv morphine provide infants effective postoperative analgesia, although side effects are common. Epidural morphine gives satisfactory analgesia with fewer doses (less total morphine); epidural morphine 0.025 mg · kg−1 is appropriate initially. Infants receiving epidural or iv morphine analgesia postoperatively need close observation in hospital with continuous pulse oximetry.RésuméObjectifComparer deux doses épidurales de morphine en bolus avec un bolus de morphine iv administrées pour la douleur postopératoire après une chirurgie abdominale ou urogénitale chez l’enfant.MéthodesDix-huit enfants ont été répartis pour recevoir soit un bolus de morphine épidural (0,025 mg · kg−1 ou 0,05 mg · kg−1) soit un bolus de morphine iv (0,050–0,150 mg · kg−1). La douleur postopératoire était évaluée et l’analgésie pourvue sur la basé d’une échelle de douleur modifée pour la pédiatrie. Le monitorage incluait l’ECG continu, l’oxymétrie de pouls, la pneumographie par impédance avec un thermistor nasal. En postopératoire, on mesurait les courbes de réponse au CO2 et les concentrations sériques de morphine.RésultatsL’analgésie postopératoire survenait en déçà de cinq minutes, indépendamment du traitement administré. Un nombre inférieur de doses de morphine (3,8 ± 0,8 pour la dose légère [DL], 3,5 ± 0,8 pour la dose forte [DF] vs 6,7 ± 1,6 pour la morphine iv, P < 0,05) à demande a été requis pour les groupes recevant la morphine épidurale. Pour obtenir des scores satisfaisants sur l’échelle de la douleur, on a dû modifier les doses dans tous les groupes. On a noté du prurit, de l’apnée et une désaturation en oxygène dans tous les groupes. Les courbes identiques en préopératoire de la réponse au CO2 (écart, 36–41 ml · min−1 · mmHg ETco2−1 · kg−1) étaient généralement déprimées (écart, 16–27 ml · min−1 · mmHg ETco2−1 · kg−1). Les concentrations de morphine sérique, négligeables pour DL (<2 ng · ml−1), étaient identiques pour DF et iv (maximum respectif 8,5 ± 12,5 et 8,6 ± 1,4 ng · ml−1).ConclusionLa morphine épidurale et la morphine iv procurent une analgésie postopératoire suffisante aux enfant malgré des effets secondaires fréquents. La morphine épidurale a produit une analgésie satisfaisante nécessitant moins de doses (dose totale moindre); la morphine épidurale 0,025 mg · kg−1 est appropriée au début. Les enfants qui reçoivent de la morphine épidurale ou iv comme analgésique postopératoire doivent être surveillés de près à l’hôpital avec l’oxymétrie de pouls en continu.

Modification of anesthesia practice reduces catheter-associated bloodstream infections: a quality improvement initiative.

Relatively rare adverse events, such as unexpected cardiac arrest, are difficult to study in the clinical setting. These events are often unpredictable in their occurrence (prompting interest in their investigation) and do not occur with sufficient frequency in any single institution to provide an adequate sample for analysis. A disease-specific registry is an epidemiological technique that can be used to collect data on a set of relatively rare unpredictable events. This approach was adopted for investigation of cardiac arrest in children when it became apparent from analysis of malpractice claims that a significant clinical problem existed. This report provides a brief historical account of the development of the Pediatric Peri-Operative Cardiac Arrest (POCA) Registry and elaborates on the methodology including strengths, weaknesses, and practical implementation issues.