Peri-operative cardiac arrest in children as reported to the 7th National Audit Project of the Royal College of Anaesthetists
Operative cardiac arrest in children as reported to the 7th National Audit Project of the Royal College of Anaesthetists
Anaesthesia
Submitted August 2024 by Dr Heather Patterson
Read by 75 Journal Watch subscribers
The focus for the 7th National Audit Project (NAP7) was perioperative cardiac arrest. This paper by Oglesby and colleagues synthesizes the paediatric data from NAP7, highlighting risk factors and management practices in the United Kingdom. Of note, 62% of cases were assessed to have had ‘good’ quality of care, suggesting scope for improvement in the remaining cases. Review of the major findings invites reflection on these themes in the Australian and New Zealand context.
Methods
All NHS hospitals undertaking anaesthesia care in the UK were invited to participate. Data collection included a baseline survey of anaesthesia departments, 4-day activity survey (extrapolated to provide denominator data), and a 12-month prospective registry of perioperative cardiac arrests. Critically ill children undergoing anaesthesia before retrieval to tertiary centres were also included. Multidisciplinary peer review allowed qualitative analysis of events surrounding arrests.
Key Findings
• Incidence: Cardiac arrest occurred in 3 per 10, 000 paediatric cases
• Mortality: Immediate mortality rate was 17%
• Setting: 85% of cases occurred in tertiary paediatric hospitals, with 39% occurring postoperatively, primarily in paediatric ICUs.
• Precipitating events: severe hypoxaemia (22%), bradycardia (11%), and major haemorrhage (8%). Tamponade and isolated severe hypotension were important precipitants in cardiac surgery and cardiac interventional procedures.
Major themes:
• Patient factors
Highest incidence occurred in neonates, infants and children with congenital heart disease (CHD). 86% of arrests occurred in children with ASA 3 or higher. Authors noted that ASA status was under-scored in 5.8% of cases, a trend also observed in the adult data.
• Surgical factors
Majority of arrests were associated with non-elective procedures, particularly in cardiac surgery (29%), ENT (13%), interventional cardiology (12%), and lower gastrointestinal surgery (11%).
• Anaesthetic factors
The authors reported several modifiable anaesthetic factors, including inappropriate dose intravenous induction agents in hemodynamically compromised patients and high concentration volatile agents at induction. There were several cases in which bradycardia requiring chest compressions was treated with atropine or glycopyrrolate instead of adrenaline.
Monitoring was also cited as an issue, including lack of basic monitoring at induction, and inadequate monitoring during interventional cardiac procedures in patients with known CHD. In their discussion, the authors recommend early invasive BP (IBP) monitoring, with a second/additional IABP line if prolonged periods without access to an IBP placed by the proceduralist is anticipated. This recommendation is not without controversy. In practice, higher risk patients (neonates and infants with CHD) often present the greatest technical challenge and vulnerability to associated risks of IABP insertion.
• Airway management
Airway events were a major cause for postoperative arrests in PICU and NICU, including ETT dislodgement or obstruction, highlighting the importance of focused patient handover, and rescue airway plan.
Authors made comment on gaps in preparedness for paediatric airway emergencies, with 15% of departments lacking access to advanced paediatric airway equipment (e.g. video laryngoscopes) in all anaesthetising locations.
• Training and Education
While 94% of cases had a consultant present at induction, only 66% of anaesthetists had up- to-date paediatric advanced life support training, compared to 90% in adult cases. Centralisation of specialist paediatric services and the need for focused education for those not routinely anaesthetising children were noted as challenges.
Conclusion
The NAP7 findings underscore the importance of risk stratification, early appropriate monitoring, and appropriate drug selection and dosing in paediatric anaesthesia. The results are relevant to practitioners in Australia and New Zealand, particularly regarding the management of high-risk groups. The authors raise some contentious points regarding invasive blood pressure monitoring in patients undergoing interventional cardiology procedures.
