Data Submission Invited

The Pediatric Perioperative Cardiac Arrest (POCA) Registry was formed in 1994 under the combined auspices of the ASA Committee on Professional Liability and the American Academy of Pediatrics Section on Anesthesiology. The POCA Registry was designed as a follow-up to the pediatric component of the ASA Closed Claims Project, which is a structured evaluation of malpractice claims filed against anesthesiologists. The Registry provides an indepth examination of cardiac arrests in anesthetized children which hopefully will improve the understanding of the underlying mechanisms and will identify strategies for prevention.

All cardiac arrests, defined as the need for CPR, during induction or maintenance of anesthesia or in the postanesthesia care unit in children 18 years of age or younger, are eligible for inclusion. For each case which qualifies, participating institutions are asked to fill out and submit a standardized data form to the data bank maintained by the University of Washington Department of Anesthesiology as a component of the Closed Claims Project. Anonymity is maintained so that neither patient, physician nor submitting institution can be identified.

POCA Demographics

As of November 1997, 60 institutions are participating in the Registry. Eighty percent of these are university-affiliated hospitals and 44% are pediatric hospitals. In 1996, the 57 institutions during that year administered approximately 279,873 anesthetics to children and reported 67 cases of cardiac arrest (approximately 2.4 arrests per 10,000 cases).

Case Profile

A total of 262 cases have been submitted since Registry inception. In contrast to the pediatric component of the ASA Closed Claims Project, in which 43% of cardiac arrests and adverse outcomes in children were attributed to respiratory events¹, only 9% of cases submitted to the POCA Registry had respiratory causes of cardiac arrest, while 38% had cardiovascular causes. The predominance of cardiovascular events compared to respiratory events in the POCA registry may have some relationship to the frequent use of pulse oximetry and capnometry (98% and 86% respectively). This relationship has been noted recently in the overall database of the Closed Claims Project. Specifically, the relative frequency of respiratory events is higher and that of cardiovascular events is lower in claims in which neither pulse oximetry nor capnometry are used, compared to claims in which pulse oximetry and capnometry are used alone or in combination.

Importance of Age and ASA Physical Status

Age was correlated with ASA physical status and outcome of cardiac arrest, as shown in the Table.

Age and ASA Status of Pediatric Cardiac Arrest Patients

	All ages	< 1 month	1-5 months	6-12 months	>12 months
n	262	65	64	32	101
ASA 1-2	50(19%)	6(9%)	11(17%)	9(28%)	24(24%)
ASA 3-5	212(81%)	59(91%)	53(83%)	23(72%)	77(76%)
mortality	122(47%)	43(66%)*	25(39%)+	12(38%)+	42(42%)+

* more than expected by chance alone (p<0.01 by Chi square) + fewer than expected by chance alone (p<0.01 by Chi square)

Children under one month of age accounted for 25% of all arrests and had a mortality rate (66%) that was much higher than for any other age group. In this youngest group, both incidence and outcome of cardiac arrest were probably influenced by underlying patient condition; 91% were ASA Physical Status 3-5.

Children from 1-5 months of age accounted for an additional 24% of arrests. Interestingly, the mortality rate (39%) in this group was less than the mortality rate for children under one month of age. Collectively, children under six months and 12 months of age accounted for 49% and 61% of all arrests, respectively.

Several previous studies have suggested that children under one year of age have the highest risk during anesthesia.^2,3 The POCA Registry data further define this; even within the under one year group, risk of cardiac arrest is inversely proportional to age, with the highest risk in the less than one month group. This finding is consistent with data from Cohen et al.⁴

Cardiac Arrest in Previously Healthy Children

ASA Physical Status 1 and 2 patients accounted for 19% of all cases. Although cardiac arrest in this group also was frequently ascribed to cardiovascular causes (28%), problems with drug administration (i.e. relative anesthetic overdose, wrong dose, wrong drug and allergic reaction) were seen in 26% of cases compared to 6% in ASA Physical Status 3-5 (p<0.05). The impact of anesthesia was described by the institutional reviewers as a major or total cause of cardiac arrest in 77% of ASA Physical Status 1 and 2 patients, compared to only 27% of ASA Physical Status 3-5 patients. Outcome was better in ASA 1-2 patients, with 6% mortality, compared to 55% mortality in ASA Physical Status 3-5 patients.

Additional POCA Participants Sought

The POCA Registry Director is Jeffrey Morray, M.D. Other members of the Registry Steering Committee include Jeremy Geiduschek, MD, Alvin Hackel, MD, Chandra Ramamoorthy, MD, Frederick Cheney, MD, Robert Caplan, MD, Karen Posner, PhD, and Karen Domino, MD. The Steering Committee would like to increase the size of the Registry as well as the participation of community-based hospitals. All university-affiliated and community-based anesthesia departments which care for children and would like to participate in the Registry are encouraged to do so. All necessary information can be obtained by contacting the POCA Registry c/o:

Karen Posner, PhD Department of Anesthesiology Box 356540, Seattle, WA 98195-6540 Tel: 206-543-2476 E-mail: [email protected]

Dr. Morray is the Director of the POCA Registry and is Director of the Department of Anesthesia and Critical Care at Children’s Hospital and Regional Medical Center in Seattle and Professor of Anesthesiology and Pediatrics at The University of Washington School of Medicine.

References

1. 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.

2. Olsson GL, Hallen B: Cardiac arrest during anesthesia. A computerized study in 250,543 anaesthetics. Acta Anaesthesiol Scand 1988; 32: 653-664.

3. Tiret L, Nivoche Y, Hatton F, Desmonts JM, Vourc’h G: Complications related to anaesthesia in infants and children. Brit. J. Anaesth 1988; 61: 263-269.

4. Cohen MM, Cameron CB, Duncan: Pediatric anesthesia morbidity and mortality in the perioperative period. Anesthe Analg 1990; 70: 160-167.