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  1. Highest risk patients for cardiopulmonary resuscitation (CPR) include infants under one year of age, ASA Physical Status Classification ≥3, and children having cardiac surgery.

  2. The American Heart Association (AHA) adopted a major change to the sequence of chest compressions and ventilation from Airway-Breathing-Circulation (ABC) to Circulation-Airway-Breathing (CAB).

  3. Medication-related intraoperative cardiac arrest is commonly associated with local anesthetic toxicity and anaphylaxis secondary to antibiotic or muscle relaxant administration.

  4. The alpha agonist action of epinephrine is probably the most important in increasing coronary blood flow to maintain myocardial blood flow and in providing cerebral blood flow with peripheral vasoconstriction.

  5. If available, capnography should be used during CPR with target end-tidal CO2 (ETCO2) of ≥15 mm Hg.

  6. During the postresuscitative phase the patient is at the highest risk for brain injury, ventricular arrhythmias, and reperfusion injury.

  7. Avoidance of hyperthermia should be a periresuscitation goal.

  8. Extracorporeal Life Support (ECLS) should be considered in reversible causes that include hyperkalemia, local anesthetic toxicity, general anesthetic overdose, and airway emergency.


Perioperative cardiac arrest is rare and the incidence in children can be difficult to define as the time frame for anesthesia-related cardiac arrest can range from intraoperative up to 30 days postoperatively.1 There is a discrepancy in whether studies include events during cardiac surgery or noncardiac cases. It is estimated that in-hospital pediatric cardiac arrest involves 5000 to 10,000 children per year in the United States.2,3 Pediatric perioperative cardiac arrests excluding cardiac surgery have been found to occur in 2.9 to 7.4 per 10,000 procedures.4,5 The incidence of specific anesthesia-related cardiac arrests when cardiac surgery is included ranges from 0.8 to 4.6 per 10,000 procedures with the highest incidence of 79 to 127 per 10,000 procedures in cardiac surgery.4,6

Beyond those having cardiac surgery, the highest risk patients include infants under 1 year of age (greatest in neonate) and those with an ASA physical status of 3 or higher.4,5,7 The etiology of cardiac arrest can be divided into four broad categories to include medication-related (anesthesia overdose), cardiovascular (hypovolemia), respiratory, and equipment-related causes.8 Within these categories the most common causes associated with perioperative pediatric arrest include hypovolemia, hyperkalemia, laryngospasm, inhaled induction, central-line complications, venous air embolism, and hypoxia.9 Cardiovascular (CV) etiologies make up 40% of anesthesia-related cardiac arrests with decreased intravascular volume being the most common culprit. Hypovolemia due to unrecognized ongoing hemorrhage is the most common cause of intraoperative hypovolemia and is worsened by the lack of vital sign variations (e.g., lack of heart rate increase) and inadequate IV access for appropriate resuscitation.4,7,9 Following CV causes, respiratory etiologies make up about 31% of cardiac arrest related to anesthesia in children and involve inadequate ventilation, inadequate oxygenation, and the “loss of airway” in the form of laryngospasm, bronchospasm, and airway difficulty.4,7

Determining the outcome for pediatric ...

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