Perioperative Cardiac Arrest in Children: Should we institute mandatory retirement?
Myron Yaster, MD and Justin L. Lockman, MD, MSEd
Today, December 7th, is Pearl Harbor Day, “a date which will live in infamy.” On December 7, 1941 “the United States of America was suddenly and deliberately attacked by the naval and air forces of the Empire of Japan." America declared war on Japan and subsequently on Nazi Germany, and thus America entered into World War II. If you can take a moment of silent reflection to remember those who gave their lives so that unspeakable evil could be defeated and we could live in freedom…
On the first day of my (Myron) anesthesia rotation at the Philadelphia VA, Ted Smith, the legendary chief of the anesthesia service, made me and the other new residents on the rotation play the computer game PONG on his Apple II computer. Pong was essentially a ping pong game that was the first personal computer “hit.” Primitive by today’s standards, it required hand eye coordination to play. After establishing a performance baseline, he insisted we play the game every morning before setting up for the day’s cases. If we were off our baseline he’d send us home, telling us “to rest and come back the next day.” I have no idea whatever happened to those data and I don’t think that his “experiment” has ever been repeated but it still makes sense to me. If we were off our game for whatever reason, vigilance and performance (and perhaps outcomes) might be affected. Which brings us to today’s PAAD. As people age, cognitive function, reflexes, hearing, and eyesight may deteriorate. The airline industry has mandatory retirement for pilots for these reasons. Are older anesthesiologists (gulp… me) less safe than younger ones? Do cardiac arrests occur more frequently when older attendings are assigned to cases? Should there be mandatory retirement ages for pediatric anesthesiologists (and other OR personnel)? Today’s PAAD addresses some of these questions. As an “alta cocker” (“old fart”) I clearly have a conflict of interest, so I’ve asked Justin Lockman, the PAAD’s primary critical care reviewer, to join me for today’s PAAD. Myron Yaster MD
Original article
Christensen R, Haydar B, Leis A, Mentz G, Reynolds P. Anesthesiologist-related factors associated with risk-adjusted pediatric anesthesia-related cardiopulmonary arrest: a retrospective two level analysis. Paediatr Anaesth. 2021 Dec;31(12):1282-1289. PMID: 34328691
Fortunately, perioperative cardiac arrests (POCA) in children are quite infrequent. Known risk factors include congenital heart disease, young age, higher ASA Physical Status, emergency surgery, off hours, and off site/non-operating room locations.(1-4) Recent studies have suggested a higher risk of anesthesia-related cardiac arrest for patients of both older anesthesiologists and those with fewer annual days delivering anesthetics. (5)
This single institutional study (Mott Children’s Hospital, University of Michigan) looked at 10-years’ worth of data and found that most anesthesia-related cardiac arrests occurred in the operating rooms (75%) during daytime/usual hours (91%), and on weekdays (95%). Twelve percent occurred in radiology suites and another 12% in the cath lab. Supervision was split between CRNAs and anesthesiology trainees (residents and pediatric anesthesia fellows), and cases staffed by CRNAs were less likely to suffer cardiac arrest than those staffed by trainees.
Consistent with other studies, patient risk factors like ASA Physcial Status >2, emergency surgery, age (especially less than 180 days) and cardiac surgery were associated with higher risk. The anesthesia-related POCA rate of 7/10,000 cases was higher than in previous studies, but there were no anesthesia-related cardiac arrests in patients with ASA Physical Status 1 or 2.
Anesthesiologist-related risk factors were assessed, including academic rank, years of experience, recent case mix, and frequency (days per year) of clinical pediatric anesthesia practice. Importantly, the authors were unable to replicate the findings of pediatric attending anesthesiologist-related risk factors for cardiac arrest; they found that case mix explained all associations between anesthesiologist-related risk factors and the cardiac arrest rate at their institution.
In the June 3rd 2021 PAAD, “Does experience matter?” we discussed an adult anesthesiology paper by Saager et al. entitled “Do It Often, Do It Better: Association Between Pairs of Experienced Subspecialty Anesthesia Caregivers and Postoperative Outcomes. A Retrospective Observational Study” [Anesth Analg 2021 Mar 1;132(3):866-877. PMID: 33433116] which found that anesthesia provider experience made a huge difference in perioperative complications. A similar study has never been performed in pediatric anesthesia.
Returning to Myron’s opening remarks: Should there be mandatory retirement ages for pediatric anesthesiologists? Would yearly cognitive, hearing, and/or vision testing for providers above a certain age be valuable as part of a decision-making algorithm? Should such testing be required of all providers of all ages or incorporated into MOCA? Would such testing even be compliant with human resources / disability law? Should Ted Smith’s idea of daily video game performance testing be rethought and brought into practice? Lots of questions, and sadly very few answers. Right now, there are insufficient data to make any of these recommendations, so I (Justin) think all of us can keep practicing for now. Discovering such data would require multi-institutional studies and would be a lot of work. One question we have for our readers: When has “a lot of work” stopped the outstanding and inquisitive minds of our SPA members before?
Myron Yaster, MD and Justin L. Lockman, MD, MSEd
References
1. Christensen RE, Lee AC, Gowen MS, Rettiganti MR, Deshpande JK, Morray JP. Pediatric Perioperative Cardiac Arrest, Death in the Off Hours: A Report From Wake Up Safe, The Pediatric Quality Improvement Initiative. Anesth Analg 2018.
2. Morray JP. Cardiac arrest in anesthetized children: recent advances and challenges for the future. PaediatrAnaesth 2011;21:722-9.
3. Ramamoorthy C, Haberkern CM, Bhananker SM, Domino KB, Posner KL, Campos JS, Morray JP. Anesthesia-related cardiac arrest in children with heart disease: data from the Pediatric Perioperative Cardiac Arrest (POCA) registry. Anesth Analg 2010;110:1376-82.
4. Uffman JC, Tumin D, Beltran RJ, Tobias JD. Severe outcomes of pediatric perioperative adverse events occurring in operating rooms compared to off-site anesthetizing locations in the Wake Up Safe Database. Paediatr Anaesth 2019;29:38-43.
5. Zgleszewski SE, Graham DA, Hickey PR, Brustowicz RM, Odegard KC, Koka R, Seefelder C, Navedo AT, Randolph AG. Anesthesiologist- and System-Related Risk Factors for Risk-Adjusted Pediatric Anesthesia-Related Cardiac Arrest. Anesth Analg 2016;122:482-9
While this article is reassuring in that case mix/complexity is likely the main determinant of intraoperative cardiac arrest, there is a a worrisome "excerpt" or talking point within the paper that I am not sure is accurate: "Supervision was split between CRNAs and anesthesiology trainees (residents and pediatric anesthesia fellows), and cases staffed by CRNAs were less likely to suffer cardiac arrest than those staffed by trainees" While in their dataset it appears that overall cases were split about 50/50 between supervising CRNAs and trainees (residents fellows), that does not mean that complexity of cases were distributed evenly between the two. The largest proportion of arrests occurred in cardiac OR cases and "offsites" . As a fellowship program director, I know that staffing preference for complex cases such as cardiac cases (including cath lab) and infants <180 days goes primarily to our fellows and upper level residents, and these patients who are more likely to suffer anesthesia related cardiac arrest. It could well mean that "cases staffed by CRNAs were more likely to be ASA 1 or 2 patients". However, I don't know how the ORs at Mott are staffed, and we don't know how case complexity is distributed between CRNAs and trainees in this study. Because the journal is British, the publishers are probably unaware of how loaded a statement that is, particularly when taken out of context. I can now quote a major anesthesia journal that says "...Cases staffed by CRNAs were less likely to suffer cardiac arrest than those staffed by physicians (resident/fellows)" The readers of PAAD know that there was a supervising physician in this mix that had ultimate responsibility, but that quote taken out of context supports the AANA stance that independent care by CRNAs is "as safe" as that of anesthesiologists. This is not in any way to disparage our CRNA colleagues, and I fully support the care team model, but I am very concerned that this pull quote will be misrepresented.
Abstract from World Congress of Anesthesia:
September 1 5, 2021
2 1309
Peri-operative Neonatal Resuscitation for Pediatric Anesthesiologists
Camila Walters, Jonathan Niconchuk, J. Matthew Kynes, Bruce Randall Brenn
Introduction: The Neonatal Resuscitation Protocol (NRP) was created by the American Heart Association for the treatment of neonates experiencing cardiac arrest. It is endorsed by the American Academy of Pediatrics. Most pediatric anesthesiologists, however, are not trained to use NRP and training is not part of most anesthesia residencies or fellowships. Young infants may receive NRP in intensive care units but receive Pediatric Advanced Life Support (PALS) in operating rooms (ORs). Use of a different and inferior algorithm for neonates and young infants may result in injuries secondary to focusing on cardiac rather than ventilatory etiologies. We measured perioperative arrest events in children <90 days prior to implementing an NRP initiative.
Methods: A retrospective review of electronic medical records at a large referral children's hospital was undertaken between 2/2004 and 8/2019. The query included neonates (<30 days) and young infants (<90 days) who received 3 or more doses of epinephrine in the OR. This critical event was deemed a surrogate for cardiac arrest, as there is no regularly used anesthesia EMR arrest event. Inhospital deaths were noted.
Results: The measured events occurred in 930 young infant OR cases, including 747 neonates and
851 cardiac cases. Of the 79 noncardiac cases, 52 (66%) were neonates, and 31 (39%) had congenital heart disease (CHD). There were 28 deaths (35%) in the 79 noncardiac cases, 15 in the CHD group and 13 in the non-CHD group. There were 21 total deaths in neonates (40%). Within the CHD group for noncardiac surgery, 49% died. All deaths were post-operative.
Conclusions: Multiple doses of epinephrine were used in 79 noncardiac cases followed by a high inhospital mortality rate. Perioperative cardiac arrest occurs in the neonatal and young infant population, and therefore it is important for pediatric anesthesiologists to train to most effectively resuscitate these patients.
[Cardiac cases are staffed by CRNAs, fellows when rotating through, general cases by a combination CRNAs, residents, fellows - did not pull this data specifically]