Sanjay M. Bhananker

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.

Injury and liability associated with monitored anesthesia care: a closed claims analysis.

Background:To assess the patterns of injury and liability associated with monitored anesthesia care (MAC) compared with general and regional anesthesia, the authors reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1990. Methods:All surgical anesthesia claims associated with MAC (n = 121) were compared with those associated with general (n = 1,519) and regional (n = 312) anesthesia. A detailed analysis of MAC claims was performed to identify causative mechanisms and liability patterns. Results:MAC claims involved older and sicker patients compared with general anesthesia claims (P < 0.025), often undergoing elective eye surgery (21%) or facial plastic surgery (26%). More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims. In contrast, the proportion of regional anesthesia claims with death or permanent brain damage was less (P < 0.01). Respiratory depression, after absolute or relative overdose of sedative or opioid drugs, was the most common (21%, n = 25) specific damaging mechanism in MAC claims. Nearly half of these claims were judged as preventable by better monitoring, including capnography, improved vigilance, or audible alarms. On-the-patient operating room fires, from the use of electrocautery, in the presence of supplemental oxygen during facial surgery, resulted in burn injuries in 20 MAC claims (17%). Conclusions:Oversedation leading to respiratory depression was an important mechanism of patient injuries during MAC. Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries. Awareness and avoidance of the fire triad (oxidizer, fuel, and ignition source) is essential to prevent on-the-patient fires.

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.

The risk of anaphylactic reactions to rocuronium in the United States is comparable to that of vecuronium: an analysis of food and drug administration reporting of adverse events.

Published reports from France and Norway suggest a frequent incidence of anaphylaxis to rocuronium and have raised concerns about its safety. We hypothesized that the Food and Drug Administration Adverse Event Reporting System could be used to confirm whether there has been an unusual incidence of anaphylactic events for rocuronium in the United States (U.S.) and whether the reporting patterns differ within and outside of the U.S.. We queried the Food and Drug Administration Adverse Event Reporting System for 1999 through the first quarter of 2002 for all adverse events for the drugs rocuronium and vecuronium and then searched on the terms considered to represent possible anaphylaxis using proprietary software. We compared the frequency of these terms in data both for rocuronium and vecuronium. We then assessed the occurrence of reports of anaphylaxis-related terms in reports from the U.S. compared with reports originating outside of the U.S.. For rocuronium, the database contained 311 reports, 166 domestic and 145 from foreign sources. Fifty percent of the foreign reports contained an anaphylaxis term versus 20% of the domestic reports (P < 0.001). For vecuronium, the comparable figures were 17% and 19% (not significant) and the total number of reports was 243. The incidence of the reports containing anaphylaxis terms did not differ between vecuronium and rocuronium in the U.S. but were significantly different for foreign reports (P < 0.001). These data confirm that U.S. anesthesia providers have not observed a significant difference in anaphylactic reactions between the two commonly used intermediate-acting muscle relaxants and suggest that frequency of reports of anaphylaxis may be significantly influenced by the area from which the reports originate.

Operating room fires: a closed claims analysis.

Background:To assess patterns of injury and liability associated with operating room (OR) fires, closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1985 were reviewed. Methods:All claims related to fires in the OR were compared with nonfire-related surgical anesthesia claims. An analysis of fire-related claims was performed to identify causative factors. Results:There were 103 OR fire claims (1.9% of 5,297 surgical claims). Electrocautery was the ignition source in 90% of fire claims. OR fire claims more frequently involved older outpatients compared with other surgical anesthesia claims (P < 0.01). Payments to patients were more often made in fire claims (P < 0.01), but payment amounts were lower (median

Intraoperative neuromuscular monitoring site and residual paralysis.

120,166) compared to nonfire surgical claims (median

Resident work hours

250,000, P < 0.01). Electrocautery-induced fires (n = 93) increased over time (P < 0.01) to 4.4% claims between 2000 and 2009. Most (85%) electrocautery fires occurred during head, neck, or upper chest procedures (high-fire-risk procedures). Oxygen served as the oxidizer in 95% of electrocautery-induced OR fires (84% with open delivery system). Most electrocautery-induced fires (n = 75, 81%) occurred during monitored anesthesia care. Oxygen was administered via an open delivery system in all high-risk procedures during monitored anesthesia care. In contrast, alcohol-containing prep solutions and volatile compounds were present in only 15% of OR fires during monitored anesthesia care. Conclusions:Electrocautery-induced fires during monitored anesthesia care were the most common cause of OR fires claims. Recognition of the fire triad (oxidizer, fuel, and ignition source), particularly the critical role of supplemental oxygen by an open delivery system during use of the electrocautery, is crucial to prevent OR fires. Continuing education and communication among OR personnel along with fire prevention protocols in high-fire-risk procedures may reduce the occurrence of OR fires.

Liability related to peripheral venous and arterial catheterization: a closed claims analysis.

Background:Residual paralysis is common after general anesthesia involving administration of neuromuscular blocking drugs (NMBDs). Management of NMBDs and reversal is frequently guided by train-of-four (TOF) monitoring. We hypothesized that monitoring of eye muscles is associated with more frequent residual paralysis than monitoring at the adductor pollicis. Methods:This prospective cohort study enrolled 180 patients scheduled for elective surgery with anticipated use of NMBDs. Collected variables included monitoring site, age, gender, weight, body mass index, American Society of Anesthesiologists physical status class, type and duration of surgery, type of NMBDs, last and total dose administered, TOF count at time of reversal, dose of neostigmine, and time interval between last dose of NMBDs to quantitative measurement. Upon postanesthesia care unit admission, we measured TOF ratios by acceleromyography at the adductor pollicis. Residual paralysis was defined as a TOF ratio less than 90%. Multivariable logistic regression was used to account for unbalances between the two groups and to adjust for covariates. Results:150 patients received NMBDs and were included in the analysis. Patients with intraoperative TOF monitoring of eye muscles had significantly greater incidence of residual paralysis than patients monitored at the adductor pollicis (P < 0.01). Residual paralysis was observed in 51/99 (52%) and 11/51 (22%) of patients, respectively. The crude odds ratio was 3.9 (95% CI: 1.8–8.4), and the adjusted odds ratio was 5.5 (95% CI: 2.1–14.5). Conclusions:Patients having qualitative TOF monitoring of eye muscles had a greater than 5-fold higher risk of postoperative residual paralysis than those monitored at the adductor pollicis.

Bilateral tension pneumothoraces following jet ventilation via an airway exchange catheter.

Purpose of review The Accreditation Council for Graduate Medical Education has mandated new requirements for work hours for all US resident physicians that became effective in July 2003. Member countries of the European Union are also implementing a reduction in work hours for trainee physicians as per the European Work Time Directives. The following review provides a summary of the basis of limiting work hours for residents, steps taken towards limiting the working hours for resident doctors, and implications to residents, institutions, and states. Recent findings Reduction of work hours for physicians in training is a much awaited and necessary change. Though the framework for such a reduction is in place in most countries, implementation of the policies has been slow thus far, mainly due to financial and manpower constraints. Setting of deadlines for compliance and legislation to penalize the defaulting institutions and programs may help to put the recommendations on work hours into practice. Summary Long work hours contribute to stress, fatigue, and mood changes in trainee physicians that are potentially deleterious to the physician and patients. Recommendations have been made across the globe to reduce resident doctor work hours and legislation is in place to monitor institutional compliance with these recommendations. Once these regulations are complied with, follow-up studies will be needed to evaluate their effects on physician well-being and patient care.

Pediatric airway management

BACKGROUND: Serious complications after peripheral IV and arterial vascular cannulations have been reported. To assess liability associated with these peripheral vascular catheters for anesthesiologists, we reviewed claims in the American Society of Anesthesiologists Closed Claims database. METHODS: Claims related to peripheral vascular catheterization were categorized as related to IV or arterial catheters. Complications related to IV catheters were categorized as to type of complication. Patient and case characteristics, severity of injury, and payments were compared between claims related to IV catheters and all other (nonperipheral catheter) claims in the database. Payment amounts were adjusted to 2007-dollar amounts using the consumer price index. RESULTS: Claims related to peripheral vascular catheterization accounted for 2% of claims in the database (n = 140 of 6894 claims), most (91%) associated with IV catheters (n = 127). The most common complications were skin slough (28%), swelling/infection (17%), nerve damage (17%), fasciotomy scars (16%), and air embolism (8%). Approximately half of these complications (55%) occurred after extravasation of drugs or fluids. Compared with other claims, IV claims involved a larger proportion of cardiac surgery (25% vs 2% for other, P < 0.001) and smaller proportion of emergency procedures (8% vs 22% for other, P < 0.001). Claims related to arterial catheters were few (n = 13, 8%), with only seven associated with radial artery catheterization. CONCLUSIONS: Claims related to IV catheters were an important source of liability for anesthesiologists, approximately half of which resulted from extravasation of drugs or fluid. Claims related to radial arterial catheterization were uncommon.