Remembering the Classics: Pediatric Perioperative Cardiac Arrest-the POCA Data
Alan Jay Schwartz, MD, MSEd
Nineteen years ago-that is when the modern-day evidence-based understanding of pediatric perioperative cardiac arrest began. Today’s understanding has been secured by scaffolding database analyses.
The foundation of the scaffold arose from the ASA Closed Claims initiative. “The American Society of Anesthesiologists (ASA) and the University of Washington at Seattle started the Anesthesia Closed Claims Program in 1984 to analyze closed malpractice claims and trends in anesthesia-related patient safety topics. Starting in 2019, the Program came under the auspices of the Anesthesia Quality Institute. The Anesthesia Closed Claims Program’s goal is to identify anesthesia-related major safety concerns, patterns of injury and prevention strategies in areas where anesthesiologists provide care. To achieve this goal, ASA member anesthesiologists collect both quantitative and qualitative data to identify a sequence of events concluding in a narrative summary of care from malpractice insurance companies. The evaluated claims can be classified as rare and/or serious events. Analyzed data can be used in publications, presentations and/or research studies”.1
Questions about pediatric cardiac arrest catastrophes started when in 1993, Jeff Morray and colleagues2 compared such events in adult and pediatric populations. They noted a higher incidence of respiratory events and mortality in pediatric patients. These factors sparked more specific questions about the etiology of pediatric perioperative cardiac arrest.
In 1994, a subset of the Closed Claims Project, the Pediatric Perioperative Cardiac Arrest (POCA) Registry, was launched. This voluntary enrollment database anonymously collected information from US and Canadian hospitals caring for children, <18 years old who sustained a perioperative cardiac arrest.
In 2000, the second level of the scaffold of evidence-based understanding of pediatric perioperative cardiac arrest was built with publication of POCA Registry data (1994-1997), reporting 150 anesthesia related perioperative cardiac arrests3:
1. 37% of these arrests resulted from medication problems, 66% of which were Halothane associated
2. 32% of the arrests resulted from cardiovascular (CV) causes, 30% of which were hemorrhage or inadequate fluid administration
3. 20% of the arrests resulted from respiratory causes, 57% of which were laryngospasm and airway obstruction
4. 33% of all arrests occurred in ASA PS 1-2 patients
5. ASA PS 3-5 was the strongest predictor of mortality
Rothstein’s editorial4 accompanying this first publication of POCA Registry findings, appropriately acknowledged that despite flaws in the data generation process, clues to better patient care were revealed. Scrutiny of Halothane use, and clinician appreciation of unrecognized hypovolemia are 2 shining examples.
In 2007, the scaffold of evidence-based understanding of pediatric perioperative cardiac arrest grew taller with publication of more POCA Registry data (1998-2004), reporting an additional 193 anesthesia related perioperative cardiac arrests5:
1. 18% of these arrests resulted from medication problems compared with 37% from 1994 to 1997, due to reduction in Halothane use in the latter period
2. 41% of the arrests resulted from CV etiologies including hemorrhage and transfusion related hyperkalemia
3. 27% of the arrests resulted from respiratory etiologies with laryngospasm and airway obstruction the most common
4. Cause of arrest was related to the phase of anesthesia care with CV and respiratory causes occurring most commonly in the surgical and postsurgical phases, respectively
5. 75% of the arrests occurred in ASA physical status 3–5 patients
6. Fewer ASA PS 1 patients in 1998–2004 arrested (7%) compared to 1994–1997
In 2010, the next phase of scaffold building of evidence-based understanding of pediatric perioperative cardiac arrest considered POCA data of a specific subset of pediatric perioperative cardiac arrest patients, ie, children with heart disease.6 From 1994 to 2005, POCA data focused on 373 anesthesia-related cardiac arrest patients, 34% of whom had congenital or acquired heart disease (HD).
1. Of the 127 children with HD who arrested, they were more likely ASA PS 3-5 and to arrest from CV causes
2. Mortality was higher in patients with HD than those without HD but did not differ when adjusted for ASA PS
3. 54% of the arrests in patients with HD occurred in the general operating room (OR) setting compared with 26% from the cardiac OR and 17% from the catheterization laboratory
4. Most common category of HD in patients suffering arrest was single ventricle
5. Most arrest patients with congenital HD were unrepaired (59%) or palliated (26%).
6. Mortality was highest in arrest patients with aortic stenosis and cardiomyopathy
What makes these publications classic and evergreen? Analyses of POCA data has facilitated development of evidence-based guides about etiologies of perioperative cardiac arrest and safer anesthetic management to reduce incidence and treat if this occurs. This has been a process of many years collecting information and using it to build the stronger and higher scaffold of understanding of this high acuity clinical problem. Revelations from the POCA data have alerted clinicians to such issues (not excluding others) as, 1) being especially cautious of the potential magnitude of Halothane CV depression, 2) recognizing that unlike adults whose blood pressure (BP) dwindles when hypovolemia develops sparking earlier intervention, children are able to compensate (eg raise their heart rate) and maintain perfusion delaying therapy until an underappreciated voluminous fluid deficit occurs and manifests when their BP plummets like falling off a cliff, 3) being alert for laryngospasm, throughout the entire perianesthetic period, the ever present life threatening emergency, 4) administering blood acutely aware of hyperkalemia risk, 5) grasping the nuances of pediatric heart disease and its risk for CV catastrophe.
PS from Myron: I know many of you know of halothane only as a historical curiosity akin to ether and cycloproprane. Halothane (RIP) was a GREAT vapor anesthetic and yes, it had problems, hepatitis, CV depression and, if one is a cynic, its very, very low cost (about $5/bottle). The CV depression was probably more related to how the vaporizer that delivered it was designed than the drug itself. The halothane vaporizer, if turned to its maximum, allowed 5% delivered halothane vapor or 4-5+ MAC equivalents (endtidal MAC was 0.7%) (FA/Fi roughly 60%). If sevoflurane’s vaporizer delivered an equivalent amount of sevoflurane it would be designed to allow a maximum of 15% sevoflurane rather than the 8% of its current design (sevoflurane’s MAC is around 2.2%, FA/Fi roughly 80%) which therefore delivers about 2.5-3 MAC. Lowering the maximum allowable sevoflurane to 8% was safety and marketing genius and put the spike into halothane’s coffin.
References
1. American Society of Anesthesiologists: Closed Claims: Anesthesia Quality Institute, 2022
2. Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW: A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology 1993; 78: 461-467
3. Morray JP, Geiduschek JM, Ramamoorthy C, Haberkern CM, Hackel A, Caplan RA, Domino KB, Posner K, Cheney FW: Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology. 2000; 93: 6-14
4. Rothstein P: Bringing light to the dark side. Anesthesiology 2000; 93: 1-3
5. Bhananker SM, Ramamoorthy C, Geiduschek JM, Posner KL, Domino KB, Haberkern CM, Campos JS, Morray JP: Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. 2007; 105: 344-350
6. 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