Reader's Responses Dec 6-10
From Audra Webber (and many others) responding to Dec 7th PAAD: Perioperative Cardiac Arrest in Children: Should we institute mandatory retirement?
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.
From Justin Lockman: Completely agree with your concerns about the authors’ statement. They do say that all of the variability can be explained by case mix, which I think is exactly your point. I agree – in my own institution it’s very unlikely that arrests happen in CRNA cases because they are not usually caring for ASA 4 and 5 patients. That said, there really are insufficient data to support one way or the other – that’s why we should study this nationally!
From Mark Schreiner: In the December 7th PAAD, there was a statement that the impact of attending experience on outcome hadn’t been reported in the context of pediatric anesthesia. In 1995, my colleagues and I conducted a nested case-control study to determine if an active URI, or a recent URI was associated with laryngospasm. We chose laryngospasm because it was the most common, severe respiratory complication in the halothane era. The risk of laryngospasm was doubled when the parent(s) thought their child had a URI. A history of a recent URI was not a risk factor. In a multi-variable analysis, several other factors proved to be significant risk factors including younger age, airway surgery and having a less-experienced attending anesthesiologist supervising. Less-experienced in our study meant that the supervising anesthesiologist was in their first year post-anesthesia residency training. The odds ratio for increased risk having a less experienced anesthesiologist was 1.69 (CI 1.04 - 2.7). While an odds ratio of 1.69 is not large it is suggestive that experience matters.
Schreiner MS, O'Hara I, Markakis DA, Politis GD. Do children who experience laryngospasm have an increased risk of upper respiratory tract infection? Anesthesiology. 1996, 85(3):475-80. PMID: 8853076.