Pediatric Perioperative Cardiac Arrest

Myron Yaster MD and Justin L. Lockman MD MSEd

Original article

Gerrit Jansen, Rainer Borgstedt, Linda Irmscher, Jakob Popp, Benjamin Schmidt, Eric Lang, Sebastian W Rehberg.  Incidence, Mortality, and Characteristics of 18 Pediatric Perioperative Cardiac Arrests: An Observational Trial From 22,650 Pediatric Anesthesias in a German Tertiary Care Hospital.  Anesth Analg. 2021 Sep 1;133(3):747-754. PMID: 33264117

Fortunately for our patients and for us, pediatric perioperative cardiac arrest (POCA) is rare, particularly if one excludes patients with congenital heart disease from the evaluation.1,2  In fact, it is rare enough that patients and some surgeons and procedurealists don’t always appreciate the anesthesiologist’s role as much as they used to, and some now worry more about long-term neurocognitive effects of anesthesia instead of worrying about death.  The APRICOT study (don’t you love these fabulous names?) was a prospective, multi-center, multinational, and pan-European study of POCA that used clearly defined definitions of severe critical events. APRICOT excluded patients who presented to the OR already intubated and those who had anesthesia induced in an ICU. Today’s study by Jansen et al. used the APRICOT cardiac arrest definition, namely the need for chest compressions and/or defibrillation, AND included patients who were induced in the ICU or presented to the OR already intubated.  To the authors, this provides us with more generalizable “real world” data for evaluation, because many of the patients at highest risk of an intraoperative arrest come emergently, or a last throw of the dice, from ICUs.

In Jansen et al.’s single institution study, 18 POCA events occurred during 22,650 anesthetic procedures (incidence 7.9 per 10,000; 95% confidence interval [CI], 4.7-12.5). Thirty-day mortality was 3.5 per 10,000 (95% CI, 1.5-6.9). Importantly, incidence and mortality were higher in children in whom anesthesia was induced in the ICU versus in the operating room (incidence: 131.6; 95% CI, 57 to 257.6 versus 4.5; 95% CI, 2.2-8.3; P < .001; and mortality: 82.2; 95% CI, 26.7-190.8 versus 1.4; 95% CI, 0.3-3.9; P < .001). Mortality for primarily circulatory-caused POCA (n = 8; 44%) was 100%, for primarily respiratory-caused (including bradycardia due to hypoxemia) POCA (n = 9; 50%) was 0% (P < .001).  One patient had two respiratory events.  Fifty percent of the POCA events were anesthesia related, including four patients with difficult airways, two mucous obstructions, one accidental intraoperative extubation, and two postoperative deaths – one from malignant hyperthemia and one from a severe “tet spell.”

As in almost all POCA studies, the incidence of POCA events and mortality following events were highest in the youngest patients.  The increased mortality in patients who were intubated and/or induced in the ICU has, to the best of our knowledge, never been previously reported – but it makes complete sense.  The numbers are startling: 1.4 (95% CI 0.3-4) per 10,000 patients induced in the OR died, whereas 82.2 (95% CI 26.7-190.9) per 10,000 patients induced in the ICU died (p<0.001).  We were also disheartened by the reported death of a teenager from Malignant Hyperthermia.  Between the MHAUS support system (, the PediCrisis app, and the availability of dantrolene (and more recently, concentrated soluble dantrolene), the mortality of MH is now less than 5%.  This is a good reminder that early recognition and treatment of this rare and dangerous condition is essential.

What is perhaps most surprising is that the highest rate of POCA was in the ASA Physical Status (PS) III group (n=12, or 66.6% of cases) compared to ASA IV (n=3) and ASA V (n=1).  In our opinion, based on the information provided about the patients, all of the patients in this study should have been classified as ASA PS IV or even V.  Lynne Ferrari and her colleagues3 have recently rethought and refined the ASA PS classification for children.  Not only does this underrating of the ASA PS impact studies such as Jansen et al, it has profound implications for pre-operative consent discussions, billing revenue, and medicolegal risks.  Whether or not our systemic underrating of ASA PS is simply due to our failure to recognize how sick patients are is a topic for another day, but we believe patients deserve to hear our honest thoughts about their anesthetic risks – and those thoughts, as Jansen would demonstrate if patients were categorized correctly, increase with increasing ASA PS score.  As a lawyer might ask:, “Why should an ASA PS II or III patient die or suffer a catastrophic injury?  After all, the anesthesiologist didn’t even think the patient was really sick.”

Myron Yaster MD and Justin L. Lockman MD MSEd


1.           Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, Leva B, Morton NS, Vermeulen PM, Zielinska M, Boda K, Veyckemans F: Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med 2017; 5: 412-425

2.           Kurth CD, Tyler D, Heitmiller E, Tosone SR, Martin L, Deshpande JK: National pediatric anesthesia safety quality improvement program in the United States. Anesth Analg 2014; 119: 112-121

3.           Ferrari LR, Leahy I, Staffa SJ, Johnson C, Crofton C, Methot C, Berry JG: One Size Does Not Fit All: A Perspective on the American Society of Anesthesiologists Physical Status Classification for Pediatric Patients. Anesth Analg 2020; 130: 1685-1692