Emergencies in pediatric anesthesia Flashcards
Risk factors for cardiac arrest include
Cardiac surgery, infants less than 1 month of age, ASA >3, prematurity, congenital heart disease, emergency procedures*****
From 1998-2004, the following reasons were attributed to intraoperative pediatric mortality:
38% <1 year of age
18-28% were “medication-related”-
Heart disease (aortic stenosis, cardiomyopathy, & single ventricle account for 75% arrests)- 54% arrested in a general OR
Declining use of _______ which was associated with bradycardia & myocardial depression.
halothane
Medication related causes of cardiac arrest during anethesia include
anesthetic overdose or relative OD of inhalational or IV agent succinylcholine-induce dysrhythmia neostigmine-induced dysrhythmia medication "swap" drug reactions unintended IV inject of LA high spinal LAST inadequate reversal of paralytic agent opioid-induced respiratory depression
Cardiovascular related causes of cardiac arrest during anesthesia include
hypovolemia** hemorrhage** inadequate volume administration** hyperkalemia caused by succinylcholine, rapid or large volume of transfusion, reperfusion, K+ administration, renal insufficiency hypocalcemia from citrate toxicity hypoglycemia vagal episodes CVC- dysthymia's, hemorrhage, tamponade embolism (air, clot, fat) MH hypothermia myocardial infarction sepsis, adrenal insufficiency
Respiratory causes of cardiac arrest during anesthesia include
inadequate oxygenation/ventilation
inability to ventilate (laryngospasm, bronchospasm, mass)
ETT misplacement, kink, plug, accidental removal
difficult airway anatomy
residual NMB
aspiration
pneumothorax
Other factors related to cardiac arrest in anesthesia include
lack of vigilance ignorance failure to apply knowledge unknown etiology surgical technique patient factors
Asystole outside of hospital is associated with
poor ROSC & survival
-often due to prolonged hypoxia and represents a terminal rhythm
Asystole in the operating room, is more likely an
initial rhythm in response to vagal stimulation
-more likely to be reversed and associated with good prognosis in the OR
Vagal stimulation can be due to
trigeminal nerve
insufflation
eyes
Vagal stimulation can be treated with
glyco
epi
atropine
& carotid massage
Prolonged arrest leads to
lengthy low-flow intervals
inadequate perfusion
myocardial & cerebral injury
The need for more than ______ minutes of CPR is a predictor of mortality
15
Up to _____ hours of CPR has been reported in anesthesia-related events with a good outcome
3
____ minutes after failed resuscitation of reversible conditions, ECMO should be activated
10
Perioperative cardiopulmonary arrest is the result of
arrest during inhalation induction (25%)- laryngospasm, agent OD, depressed myocardial function
arrest during craniofacial or spine surgery- hypovolemia/blood loss, VAE
hyperkalemia- rapid RBC transfusion
VP shunt malfunction- increased ICP
LAST
Anaphylaxis
Describe the dose of IV lipids for LAST treatment.
1.5 mL/kg of 20% lipid emulsion over 1 minute, followed by an infusion of 0.25 mL/kg/min. for 10 minutes
The steps to treating CPR include
- recognize the need
- know how to perform
- vascular access
- medications for CPR
- teamwork
- documentation
- post resuscitation care
- selfcare post a critical incident
Chest compression should begin at
<60 bpm**
Checking for a pulse in the newborn should occur at the
umbilical artery
Checking for a pulse in the infant should occur at the
brachial artery
Checking for a pulse in the child should occur at the
carotid
When initiating CPR, it is important to also remember to
administer 100% fiO2
cease all anesthetic administrations
allow for chest recoil
switch compression provider every 2 minutes
Medications that can be administered through an ETT include
NAVEL: naloxone atropine vasopressin epinephrine lidocaine
Intubation of the trachea during CPR in the OR is recommended and includes:
adequate ventilation
trained anesthesia providers place ETTs rapidly with minimal interruptions to compressions
check for correct placement
A______ puts patients at greater risk for aspiration during CPR
an unprotected airway (mask, laryngeal mask ventilation, etc.)
Defibrillation is used for the following rhythms:
vfib & vtach
at 2-4 J/kg
up to 10 J/kg
Cardioversion is used for the following rhythms:
synchronized with R wave
afib, aflutter, or SVT
0.5-1J/kg up to 2 J/kg
Attempts to obtain peripheral venous access should be limited to
90 seconds
if unsuccessful consider IO, femoral vein access, drug administration through ETT
Each drug should be flushed with
0.25 mL/kg normal saline (5 mL infants, 10 mL children)
The preferred site for placement of an IO needle in a child is
the anterior tibia
Titration of FiO2 after ROSC is generally aimed at
pulse oximetry levels of 94 to 99%
Care after ROSC, includes assessing for
rebound of arrest (i.e. hyperkalemia treatment, needle decompression of tension pneumo)
Care after ROSC includes
assess for ETT and line displacements during the arrest
accurate reporting to surgery team, family, ICU team
After ROSC, it is important to avoid
hyperthermia, hyperglycemia, & seizures
