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.
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]
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]