Calling for Help – A sign of STRENGTH, not weakness!
Tommy Rappold, Jr., MD and Justin L. Lockman, MD, MSEd
“A long time ago in a galaxy far, far away”, Dr. Genie Heitmiller and her colleagues at the Johns Hopkins Hospital performed a survey study of SPA members to evaluate pediatric anesthesiologist’s knowledge of the 2005 American Heart Association (AHA) Pediatric Advanced Life Support (PALS) recommendations. She and her colleagues found that despite the fact that 85% of the respondents were pediatric anesthesia fellowship trained, there were major deficiencies in knowledge of AHA/PALS guidelines. The authors concluded that “formal resuscitation training programs were needed.”1 Interestingly, Dr. Alan Schwartz, one of my mentors and a frequent contributor and member of the PAAD’s executive council found almost identical results 20 years before Genie’s study.2 So, when I saw and read today’s PAAD3 I immediately thought it would be a must read for all of you because so much has changed in pediatric CPR management and have we kept pace? I asked Dr. Justin Lockman, the PAAD’s ICU editor to review this paper and he asked Dr. Tommy Rappold, Jr. one of his pediatric anesthesia and PICU combined fellows to assist.
Finally, today’s PAAD is a perfect example of how pediatric anesthesia and pediatric critical care medicine when working together can improve the care of children. For those of you with Boards in both subspecialties and want a “home” to meet and work with others with the same passion and training, the SPA Special Interest Group in Pediatric Critical Care Medicine is being reconstituted and reinvigorated. Contact Dr. Tim Welch to join! Myron Yaster MD
Original Article:
Charles A, Williams SA, Dolan J, Rehman M, Arnold J, Chandler NM, Pediatric intraoperative cardiopulmonary arrests: A survey to evaluate if Medical Emergency Teams are utilized in pediatric operating rooms. Pediatr Anaesth. 2023; 33(6), pp.454-9. doi: 10.1111/pan.14665 PMID: 36932923
Today’s article by Charles et al.3 addresses a gap in the perioperative cardiopulmonary resuscitation (CPR) literature: who responds to pediatric intra-operative cardiac arrests? Through a twenty-four-question exploratory survey, the authors aimed to address the frequency with which Medical Emergency Teams (METs) are employed for pediatric intraoperative code resuscitations and to understand MET best practices. Surveys were sent to 84 members of the Pediatric Anesthesia Leadership Council (PALC) as well as to voluntary participants from the Pediatric Resuscitation Quality Collaborative (PediRES-Q).
Not surprisingly, this survey revealed that the majority of pediatric METs included pediatric nurses and physicians, respiratory therapists, and pharmacists. Moreover, a majority of nurses were ICU trained (78%), physicians were ICU-based (62%), and when an advanced practice provider responded, they were also ICU-based (86%). Hospitals affiliated with PediRES-Q had a greater percentage (60%) of METs that may respond to intra-operative code events compared to those not associated with PediRES-Q (18%). Importantly, in over 80% of cases MET involvement was at the operating room’s (OR) request only and not triggered automatically by an intraoperative emergency3.
The OR environment is often thought of as a self-contained ICU – complete with procedures, ventilators, vasoactive infusions, blood products, acute physiologic changes, and yes: CPR. Our job is to be ready for anything, and often our patients are “ICU complexity” (whether or not they start/end in the ICU). As such, the thought of requesting additional support outside of the anesthesia-trained milieu for a cardiac arrest is often not even considered.
Perhaps we have a bias about this, since we practice in both arenas. We will concede that cardiac arrest care originated in the OR in an era when intraoperative arrest was common; however, in 2023 it is far more common in the ICU than in the OR.4,5 What’s more, even those of us who practice in the ICU have recognized that we are not nearly as good as we think. ICU providers do not adhere to guidelines as much as we should, and in some places (including ours, CHOP), sub-subspecialty teams aid with post-arrest care because neuroprotection and other aspects of care have become so subspecialized. Can we realistically think that pediatric anesthesiologists, when we so rarely see intraoperative arrest, can provide better care in this setting?
As with outcomes after any rare event, it may be impossible to get a definitive answer to this question – but we would love to see SPA members collaborate with Society of Critical Care Medicine members to try. But far more importantly, we think this is not a question of “Who does it better?” Rather, this discussion should be “Can we do this better, together?” We think the answer is a resounding: “YES!”. The routine addition of ICU-trained providers responding to intra-operative codes could enhance care in several ways:
Improved cardiac arrest collaborative team training
Enhanced adherence to goal-directed post-arrest care guidelines6-8
More experienced providers in the room during cardiac arrest9
Faster ECMO cannulation times, when needed
Mental off-loading and resource coordination
Improved continuity/transition of post-arrest care from OR to ICU10
More resources, which may be particularly valuable in off-hours5
We also need to recognize the two potential downsides to such a strategy. First, having more people is not always better! This is especially a problem in a foreign environment like the OR (for intensivists). As in any crisis, resource management includes leadership, communication, role assignment, and more. The entire team would need to be on the same page about who is in charge, etc., but this can be achieved with clear communication.
Second, and the real elephant in the room: Can our egos handle it? Many of us were trained in a mental model where calling for help was a sign of weakness. Even for those of us, like me (JLL), who teach regularly about CPR and crisis resource management, there is sometimes a psychological barrier to calling for help. But when children’s lives are on the line and neurologic outcomes are dependent on superb care, shouldn’t we check our egos at the door? Are we ready to shift toward calling for help being a sign of STRENGTH?
The practice of implementing and maintaining such a model would be challenging. It would require planning, discussions of resource capacity and feasibility, and iterative evaluation for effectiveness and improvement. Centers would also need to decide whether METs should be activated automatically for intraoperative emergencies or only on request. With multidisciplinary team-based simulation, care models could be fine-tuned. And as today’s article points out, there may be other situations outside of cardiac arrest where this model may make sense (e.g., massive transfusion protocol and anaphylaxis).
Good medicine involves collaboration. We believe that this mindset is fundamental to excellent clinical care in the operating room like it is everywhere else in our hospitals. What do you think? Have you ever called the ICU team (or a MET of any kind) to the OR during a crisis? Should this become the norm? Are you strong enough to know when to call for help? Tell Myron your thoughts and he’ll post in a Friday Reader Response.
References
1. Heitmiller ES, Nelson KL, Hunt EA, Schwartz JM, Yaster M, Shaffner DH. A survey of anesthesiologists' knowledge of American Heart Association Pediatric Advanced Life Support Resuscitation Guidelines. Resuscitation. 10/25/2008 2008;79(3):499-505. Not in File.
2. Schwartz AJ, Orkin FK, Ellison N. Anesthesiologists' training and knowledge of basic life support. Anesthesiology. Mar 1979;50(3):191-4. doi:10.1097/00000542-197903000-00004
3. Charles A, Williams SA, Dolan J, Rehman M, Arnold J, Chandler NM. Pediatric intraoperative cardiopulmonary arrests: A survey to evaluate if Medical Emergency Teams are utilized in pediatric operating rooms. Paediatric anaesthesia. Jun 2023;33(6):454-459. doi:10.1111/pan.14665
4. Berg RA, Nadkarni VM, Clark AE, et al. Incidence and Outcomes of Cardiopulmonary Resuscitation in PICUs. Crit Care Med. Apr 2016;44(4):798-808. doi:10.1097/CCM.0000000000001484
5. 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. Aug 2018;127(2):472-477. doi:10.1213/ANE.0000000000003398
6. Marino BS, Tabbutt S, MacLaren G, et al. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation. May 29 2018;137(22):e691-e782. doi:10.1161/CIR.0000000000000524
7. Topjian AA, de Caen A, Wainwright MS, et al. Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation. Aug 6 2019;140(6):e194-e233. doi:10.1161/CIR.0000000000000697
8. Topjian AA, French B, Sutton RM, et al. Early postresuscitation hypotension is associated with increased mortality following pediatric cardiac arrest. Crit Care Med. Jun 2014;42(6):1518-23. doi:10.1097/CCM.0000000000000216
9. Nallamothu BK, Guetterman TC, Harrod M, et al. How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study. Circulation. Jul 10 2018;138(2):154-163. doi:10.1161/CIRCULATIONAHA.118.033674
10. Breuer RK, Taicher B, Turner DA, Cheifetz IM, Rehder KJ. Standardizing postoperative PICU handovers improves handover metrics and patient outcomes. Pediatr Crit Care Med. Mar 2015;16(3):256-63. doi:10.1097/PCC.0000000000000343