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Anesthesiology:
Clinical Investigations

Anesthesia-related Cardiac Arrest in Children: Initial Findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry

Morray, Jeffrey P. M.D.*; Geiduschek, Jeremy M. M.D.†; Ramamoorthy, Chandra M.B., B.S., FRCA†; Haberkern, Charles M. M.D., M.P.H.†; Hackel, Alvin M.D.‡; Caplan, Robert A. M.D.§; Domino, Karen B. M.D., M.P.H.∥; Posner, Karen Ph.D.#; Cheney, Frederick W. M.D.**

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Abstract

Background: The Pediatric Perioperative Cardiac Arrest (POCA) Registry was formed in 1994 in an attempt to determine the clinical factors and outcomes associated with cardiac arrest in anesthetized children.
Methods: Institutions that provide anesthesia for children are voluntarily enrolled in the POCA Registry. A representative from each institution provides annual institutional demographic information and submits anonymously a standardized data form for each cardiac arrest (defined as the need for chest compressions or as death) in anesthetized children 18 yr of age or younger. Causes and factors associated with cardiac arrest are analyzed.
Results: In the first 4 yr of the POCA Registry, 63 institutions enrolled and submitted 289 cases of cardiac arrest. Of these, 150 arrests were judged to be related to anesthesia. Cardiac arrest related to anesthesia had an incidence of 1.4 ± 0.45 (mean ± SD) per 10,000 instances of anesthesia and a mortality rate of 26%. Medication-related (37%) and cardiovascular (32%) causes of cardiac arrest were most common, together accounting for 69% of all arrests. Cardiovascular depression from halothane, alone or in combination with other drugs, was responsible for two thirds of all medication-related arrests. Thirty-three percent of the patients were American Society of Anesthesiologists physical status 1–2; in this group, 64% of arrests were medication-related, compared with 23% in American Society of Anesthesiologists physical status 3–5 patients (P < 0.01). Infants younger than 1 yr of age accounted for 55% of all anesthesia-related arrests. Multivariate analysis demonstrated two predictors of mortality: American Society of Anesthesiologists physical status 3–5 (odds ratio, 12.99; 95% confidence interval, 2.9–57.7), and emergency status (odds ratio, 3.88; 95% confidence interval, 1.6–9.6).
Conclusions: Anesthesia-related cardiac arrest occurred most often in patients younger than 1 yr of age and in patients with severe underlying disease. Patients in the latter group, as well as patients having emergency surgery, were most likely to have a fatal outcome. The identification of medication-related problems as the most frequent cause of anesthesia-related cardiac arrest has important implications for preventive strategies.
INCREASED risk of perioperative cardiac arrest in children compared with adults has been recognized since the seminal study of Beecher and Todd. 1 A number of factors associated with perioperative cardiac arrest have been identified, including young age, 2–5 comorbid conditions, and emergency surgery, 6 although the immediate cause of cardiac arrest has at times been after to identify. 7 Because anesthesia-related cardiac arrest is uncommon, a multiinstitutional database is required to more fully understand the mechanisms of cardiac arrest and to develop preventive strategies. To this end, the Pediatric Perioperative Cardiac Arrest (POCA) Registry was formed in 1994 under the combined auspices of the Committee on Professional Liability of the American Society of Anesthesiologists (ASA) and the American Academy of Pediatrics Section on Anesthesiology to investigate the causes of cardiac arrest in anesthetized children. The purpose of this report is to provide an analysis of the first 150 anesthesia-related cardiac arrests reported to the POCA Registry, with emphasis on etiology and outcome of cardiac arrest in the pediatric population.
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Methods

Following project approval by the Human Subjects Review Board of the University of Washington, voluntary enrollment of cases began in 1994 from institutions in the United States and Canada that provide anesthetic care to children. From 1994 through 1997, 63 institutions were enrolled; 75% were university affiliated and 40% were children’s hospitals. The majority of participating institutions were involved in training of fellows in pediatric anesthesia (40%) and/or residents in anesthesiology (76%) and served as tertiary referral centers for subspecialty surgical care.
Each institution was asked to designate a representative responsible for submitting demographic information, including type of institution, number and training of anesthesia providers, and number and types of cases. The institutional representatives were also asked to complete and submit a standardized data form for all cases of cardiac arrest (defined as the administration of chest compressions or as death) that occurred in children 18 yr of age or younger during administration of or recovery from anesthesia. Neonatal resuscitations and resuscitations in the pediatric intensive care unit or on the ward were excluded.
For each case meeting POCA Registry entry criteria, the following data were requested: patient demographic information, surgical procedure, personnel involved in anesthetic care, anesthetic agents, and techniques and monitors used. In addition, the report asked for specific information about the cardiac arrest, including prearrest status, antecedent events, and the immediate cause of arrest. Possible causes for cardiac arrest were defined as shown in Appendix A. The institutional representatives were asked to assess the contribution to and outcome after cardiac arrest of anesthesia, surgery, and underlying patient disease as none, minor, major, or total.
Outcome was assessed using a modification of a 10-point severity of injury scale 8 applied 24 h after the arrest and at the last clinical evaluation (median, 7 days; range, 1–448 days) if the patient survived more than 24 h (Appendix B). Autopsy findings, if available, were also included.
A narrative summary was requested from the institutional representative to specify the sequence of events and causal relations associated with the cardiac arrest and to provide any relevant information not previously included.
All cases were submitted anonymously, identified only by a one- to five-digit number assigned by the institutional representative, thereby precluding identification of the patient, health care provider or providers, or submitting institution. Following submission, each data form was entered into a database maintained at the University of Washington School of Medicine Department of Anesthesiology and managed by the ASA Closed Claims Project staff. All data forms were reviewed by one member of the POCA Registry Steering Committee for consistency and completion. Demographic data (e.g., ASA physical status) were not edited. If data were missing from the data form, an alert was sent out to all POCA Registry institutional representatives requesting information for the case as identified by the one- to five-digit number.
Three members of the POCA Registry Steering Committee independently reviewed all data forms and categorized each cardiac arrest as anesthesia-related, not anesthesia-related, or unknown according to the definitions shown in Appendix C. Cases of inability to wean from cardiopulmonary bypass or early postbypass heart failure were categorized as not related to anesthesia; none of these cases had anesthesia-related problems in the prebypass period that influenced the subsequent failure to wean from bypass. Cases of arrest due to hemorrhage were classified as anesthesia-related if anesthesia personnel could have adequately replaced blood loss or if arrest was due to metabolic consequences of massive transfusion (e.g., hyperkalemia, hypocalcemia).
Disagreements among the three members of the Steering Committee Subgroup concerning whether or not a case was anesthesia-related were resolved by discussion; unanimity was required. Cases in which agreement could not be reached or cause of arrest could not be determined were classified as unknown. Final committee assignments were compared with institutional reviewer assessments; major or total anesthesia responsibility were classified as “anesthesia-related,” and minor, none, or unknown anesthesia responsibility were classified as “unrelated to anesthesia.”
The POCA Registry Steering Committee Subgroup also independently reviewed etiology of arrest when the institutional assignment was ambiguous (i.e., presumed cardiovascular cause, unclear etiology; presumed respiratory cause, unclear etiology; multiple events; and unknown). Agreement by two of three reviewers was required to change the institutional assignment of etiology of arrest.
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Statistical Analysis
Reliability of POCA Registry Steering Committee members’ assessments of whether cases were anesthetic related was measured by the κ statistic. 9 The κ statistic was also used to measure agreement between POCA Registry Steering Committee assignments and assignments by the submitting institution. A κ value greater than 0.40 at P < 0.05 was established as an acceptable level of agreement.
All statistical analysis was restricted to cases designated by the Steering Committee as anesthesia related. The rate of perioperative cardiac arrest was calculated by dividing the total number of anesthesia-related cardiac arrests reported during each calendar year by the total number of instances of anesthetic administration by all participating institutions during that calendar year. Missing caseload data were estimated from the most recent data available. The overall 4-yr rate of arrest was calculated as the mean ± SD of the 4 yearly rates. Compliance with case reporting requirements was not measured. Categorical data were analyzed using Fisher exact test. Factors predicting mortality following cardiac arrest were analyzed with multivariate forward stepwise logistic regression with odds ratios and 95% confidence intervals reported. Variables with univariate likelihood ratio chi-square values significant at P ≤ 0.05 were included in the multivariate analysis. Significance was defined as values of P ≤ 0.05.
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Results

Table 1
Table 1
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In the first 4 yr of operation, 289 cases were submitted to the POCA Registry. Of these, 150 (52%) were anesthesia related, and the remainder were related to underlying patient disease or to the surgical process (non–anesthesia related; n = 115), or were of an undetermined cause (n = 24;table 1). POCA Steering Committee members initially agreed on their independent assignments in 69% of cases (κ = 0.64). Final POCA Steering Committee assignments agreed with the original submitting institution report 85% of the time (κ = 0.71). In the non–anesthesia-related group, 25 (22%) were cardiac surgery patients who failed to wean from cardiopulmonary bypass or had early postbypass heart failure, 20 (17%) arrested as a result of uncontrollable surgical bleeding, 25 (22%) had miscellaneous cardiovascular events, 14 (12%) had presumed cardiovascular events with unknown etiology, 5 (4%) had air embolism, 5 (4%) had complications of central venous pressure lines, and 21 (18%) had other miscellaneous causes of arrest. The remaining analysis focuses on the 150 anesthesia-related cases.
Table 2
Table 2
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During the study period, participating institutions administered anesthesia to children younger than 18 yr of age an estimated 1,089,200 times. The mean overall incidence of anesthesia-related cardiac arrest was 1.4 ± 0.45 per 10,000 instances of anesthesia per year (range, 1.1–2.1 per 10,000 instances of anesthesia per yr). The profile of the 150 cases of anesthesia-related cardiac arrest is detailed below and in tables 1 and 2. Infants younger than 1 yr of age accounted for 55% of anesthesia-related cardiac arrests (table 1). Thirty-three percent of arrests occurred in ASA physical status 1–2 patients, and 67% occurred in ASA physical status 3–5 patients. Twenty-one percent of arrests occurred during emergency surgery. General surgery (including urology) was the most common surgical category (39%); hernia repair (n = 10) and exploratory laparotomy (n = 7) were the most common procedures in this group.
General anesthesia alone was administered in most cases (88%); regional techniques were used alone or in combination with general anesthesia in 1% and 9% of cases, respectively. Monitoring devices in use at the time of cardiac arrest included pulse oximeter (99%), electrocardiograph (97%), blood pressure cuff (95%), capnograph (86%), and an inspired O2 monitoring device (86%). Most cardiac arrests occurred during induction (37%) or maintenance (45%) of anesthesia, usually following one or more of the following antecedent events: bradycardia (54%), hypotension (49%), abnormality of oxygen saturation as measured by pulse oximetry (46%), inability to measure blood pressure (25%), abnormality of end-tidal CO2 (21%), cyanosis (21%), or arrhythmia (16%). In 11% of cases, cardiac arrest occurred without recognized warning.
The causes of anesthesia-related cardiac arrest are shown in table 2. Medication-related problems were most common, accounting for 37% of all arrests. Cardiovascular depression from the administration of halothane (n = 26), halothane plus an intravenous medication (fentanyl [n = 3], bupivacaine [n = 3], lidocaine [n = 2], propranolol [n = 1], sufentanil [n = 1], or thiopental [n = 1]), or sevoflurane (n = 2) was regarded by reviewers as the primary cause in 71% of all medication cases. Median age for the 37 cardiac arrests related to halothane (either alone or in combination with an intravenous medication) was 6 months (range, 5 days–7 yr). Twenty-three of these patients were ASA physical status 1–2, and 14 were ASA physical status 3–5 (eight because of congenital heart disease). Three patients had an unrecognized cardiomyopathy. The median halothane concentration was 2%; five patients received halothane 3–3.9%, and nine received 4% or more halothane just prior to arrest. Sixty-six percent of halothane-related arrests occurred during induction, and 34% occurred during the maintenance phase. The most common antecedent events were bradycardia (n = 25) and hypotension (n = 25). An abnormality in oxygen saturation as measured by pulse oximetry was seen in 17 patients; loss of signal was the most common type of abnormality (n = 12). The most common associated factors were assisted or controlled ventilation (n = 18) and difficult intravenous access requiring multiple attempts (n = 4). Three of the 37 patients died, and two survived with permanent injury. All other cases were successfully resuscitated and recovered without permanent injury. Epinephrine alone (n = 10), atropine alone (n = 7), or epinephrine plus atropine (n = 15) were the drug treatments usually associated with return of adequate circulation.
The two arrests relating to cardiovascular depression from sevoflurane occurred during induction of anesthesia in ASA physical status 3 children and were preceded by hypotension and bradycardia. Both children were successfully resuscitated and survived without sequelae.
Five cases of arrest following intravascular injection of local anesthetic were reported. Four of these occurred during caudal injections (following induction of general anesthesia with halothane) of 0.25% bupivacaine with 1:200,000 epinephrine (0.5–1 ml/kg) through either a 23-gauge needle (n = 3), or a catheter (n = 1), despite negative aspiration and a negative test dose. All patients displayed ventricular arrhythmias. One patient was given intravenous phenytoin, and two were defibrillated. One other patient returned to sinus rhythm with only chest massage and ventilation with 100% oxygen. All four of these patients recovered without injury. The fifth case occurred following intranasal injection by the surgeon of 5 ml of 1% lidocaine with 1:100,000 epinephrine prior to endoscopic sinus surgery in a 4-yr-old boy. The administration of 4% cocaine pledgets, as well as 1% halothane, may also have contributed to this child’s pulseless ventricular tachycardia. Conversion to normal sinus rhythm was achieved via a precordial thump, and the child recovered without sequelae.
Cardiovascular causes of cardiac arrest were found in 48 cases; in 18 of these, an exact cause of cardiac arrest could not be determined. Ten of these 18 patients had underlying congenital heart disease and were ASA physical status 3–5. The most common cardiovascular category in which an exact etiology could be determined was cardiac arrest as a consequence of hemorrhage or its therapy (n = 8). In three of these cases, the arrest was at least in part caused by hyperkalemia resulting from massive transfusion.
Respiratory events accounted for 20% of all cardiac arrests; the most common etiology was airway obstruction, due either to laryngospasm or anatomic obstruction. The laryngospasm group (n = 9) tended to be previously healthy; all but three were ASA physical status 1–2. Nonetheless, all developed severe bradycardia, hypotension, or both requiring initiation of chest compression. In most cases (n = 8), laryngospasm occurred during induction with halothane and nitrous oxide. Five of the cases required succinylcholine, and all were intubated successfully. Epinephrine was required in only one patient. One patient developed aspiration pneumonia, and one patient subsequently died of massive blood loss from a sagittal sinus tear. All other patients recovered without injury.
Most of the patients who arrested from anatomic airway obstruction had significant underlying disease: two had airway compression during repair of tracheoesophageal fistula; two had severe macroglossia; one had cystic fibrosis associated with mucous plugging; one had severe papillomatosis; and one had micrognathia. Similarly, the patients who arrested because of difficult intubation had significant underlying disease, and all were 4 months of age or younger: two had congenital heart disease; one had trisomy 18; and one had Pierre-Robin–related micrognathia.
The most common equipment problems were complications of anesthesiologist-placed central lines, either from induction of an arrhythmia or from creation of tamponade, hemothorax, or pneumothorax.
Fig. 1
Fig. 1
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Thirty-three percent (n = 50) of all cardiac arrests occurred in previously healthy (ASA physical status 1–2) patients. A comparison of mechanism of arrest for ASA physical status 1–2 and ASA physical status 3–5 patients is shown in figure 1. Medication-related arrests were more common (P < 0.001) and cardiovascular etiologies were less common (P < 0.001) in ASA physical status 1–2 patients than in ASA physical status 3–5 patients.
Table 3
Table 3
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Twenty-six percent of patients died, 6% suffered permanent injury, and 68% had no injury or temporary injury. The profile of the 39 patients who died is shown in table 3. All of the patients who died had significant underlying disease. Of the two patients reported as ASA physical status 1–2 who died, one was a 15-month-old child who arrested during induction of anesthesia prior to adenoidectomy; autopsy revealed massive cardiomegaly secondary to an unsuspected cardiomyopathy. The other was a 1-yr-old child with ichthyosis, failure to thrive, and hypertonia who arrested for presumed cardiovascular reasons during induction of anesthesia prior to gastrostomy.
Congenital heart disease was present in 15 of the patients who died, including patients in the medication-related (n = 1), respiratory-related (n = 2) and equipment-related (n = 1) categories. Acquired cardiomyopathies were present in three patients, all of whom arrested from halothane-induced cardiovascular depression and could not be resuscitated. Sepsis was the underlying problem in all three patients who died because of inadequate fluid replacement. Four patients died because of massive blood loss during tumor resection; two of these patients arrested because of hyperkalemia associated with massive transfusion. Hyperkalemia played a role in the death of three other patients. Two were liver transplant patients who developed wide complex tachyarrhythmias after reperfusion and could not be resuscitated. The other was a complex patient with renal insufficiency and severe metabolic acidosis.
Table 4
Table 4
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By multivariate analysis, ASA physical status 3–5 was the strongest predictor of death. The mortality rate in ASA physical status 3–5 patients was 37%, compared with 4% in ASA physical status 1–2 patients (P < 0.001). Emergency surgery (mortality rate 52 vs. 13% in nonemergency surgery;P < 0.001), was also predictive (table 4). Age group and type of surgery were not predictive of mortality.
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Discussion

This report provides insight into the origins and outcomes of anesthesia-related cardiac arrest in children under conditions of contemporary practice in North American hospitals. Patients younger than 1 yr of age accounted for more than one half of all arrests. Medication-related and cardiovascular causes of arrest were most common, together accounting for 69% of all arrests. Severe underlying patient disease and emergency surgery were the factors most strongly associated with poor outcome following cardiac arrest in anesthetized children.
Previous authors have reported an increased incidence of perioperative cardiac arrest in infants. Rackow et al., 2 and subsequently Tiret et al.4 and Ollson et al., 3 suggested that infants younger than 1 yr of age were at increased risk. Cohen et al.5 found that the largest number of perioperative complications occurred in infants younger than 1 month of age. POCA Registry data also suggest that infants are at increased risk, although the denominators necessary to calculate age-based risk are not yet available. Severe underlying patient disease such as prematurity, congenital heart disease, and other congenital defects place the infant at higher anesthetic risk than the older child or the adult. Interestingly, age as a factor independent of underlying disease was not predictive of mortality following cardiac arrest.
Medication-related problems accounted for 37% of all arrests and 64% of arrests in previously healthy (ASA physical status 1–2) patients. The predominant mechanism of arrest in this category was cardiovascular depression from the inhalation agents, usually halothane, either alone or in combination with an intravenous medication. Of the children who arrested due to cardiovascular depression from halothane, 50% were 6 months of age or younger, and 50% had a reported inspired halothane concentration of 2% or less. This finding is consistent with the observation that young children may be vulnerable to cardiovascular depression from even conventional concentrations of halothane. 10,11 In some cases, associated factors may have contributed to cardiovascular depression by halothane. For example, the use of assisted or controlled ventilation may have accelerated the rise of halothane concentration in the blood and myocardium or may have reduced cardiac output by impeding venous return. Similarly, difficulty in gaining intravenous access may have resulted in prolonged exposure to high inspired halothane concentrations. Patients with significant underlying disease such as congenital heart disease may tolerate poorly any compromise in cardiac output caused by halothane-induced reductions in heart rate or myocardial contractility. The same is true for acquired heart disease, as illustrated by the three patients who arrested and died during induction with halothane and were found to have cardiomyopathies.
It is unclear at this time whether the increasing popularity of sevoflurane as an induction agent in children will have an impact on the number of reports of cardiac arrest attributed to inhalation agents. Sevoflurane has been reported to have less potential for producing bradycardia 12,13 and myocardial depression 14,15 than does halothane. Because denominators are not available, the incidences for halothane- and sevoflurane-related cardiac arrests cannot be calculated.
Most cases of intravascular injection of local anesthetic occurred during attempts at caudal injection despite negative aspiration and absence of response to a test dose. Incremental dosing of local anesthetic into the epidural space has been recommended over bolus injection to allow earlier detection of intravascular injection, 16 although this has not been systematically studied. Alternatively, use of local anesthetics with less myocardial toxicity than that associated with bupivacaine might be preventive.
The increased frequency of cardiovascular causes and the decreased incidence of respiratory causes of arrests differ from previous studies of anesthesia-related cardiac arrest in children. In the 1975 study of Salem et al., 17 an equal proportion of cardiac arrests was ascribed to respiratory and cardiovascular causes. In a 1985 report from Keenan and Boyan, 6 cardiac arrest in children was most commonly ascribed either to failure to ventilate or to anesthetic overdose. In the Pediatric Closed Claims Project report, respiratory causes of adverse events (including cardiac arrest) were most common, accounting for 43% of all claims, compared with only 13% in which cardiovascular causes were implicated. 7
The frequency of cardiovascular events in the POCA Registry may relate to the entry criteria:i.e., the need for chest compression. Arrests due to adverse respiratory events would not be included unless chest compressions were required. The predominance of cardiovascular events may also have some relation to the frequent use of pulse oximetry and capnography, monitors that may be more effective in preventing respiratory rather than cardiovascular events. Compared with the current report, the relative frequency of respiratory events was higher and that of cardiovascular events was lower in claims in the Pediatric Closed Claims Project report, 7 in which pulse oximetry was used in only 7% of cases. It is also possible that some events previously categorized as respiratory in the absence of pulse oximetry and capnography were actually cardiovascular in origin.
Several diagnoses are notable by their absence from the POCA Registry, including cardiac arrest from malignant hyperthermia or latex anaphylaxis. The reasons for this are unclear, but perhaps widespread recognition of these entities has reduced the routine use of triggering agents for malignant hyperthermia or the use of latex-containing products in potentially susceptible patients.
The only factors predictive of mortality following cardiac arrest were ASA physical status and emergency surgery. Although both have been reported as risk factors for anesthesia-related cardiac arrest in children, 4,6 this is the first study to identify them as factors predicting outcome from arrest. Emergency surgery as a predictor of mortality may be related to either patient factors (e.g., cause of arrest, severity of underlying disease) or environmental factors (e.g., availability of support staff or ancillary services). In our study, all deaths during emergency surgery occurred in ASA physical status 3–5 patients. There were no differences in distribution of age or cause of arrest between the emergency surgery patients who survived arrest and those that did not.
The POCA Registry has some important methodologic weaknesses. First, it depends on voluntary reporting from institutional representatives who must collate a large amount of data to report even a single case. Underreporting is likely in this situation. For example, the annual incidence-of-arrest figure may be negatively biased (i.e., lower than the actual rate of arrest). Selection bias is also possible, such that unexpected cardiac arrests or highly sensitive cases might not get reported. Although underreporting would decrease the calculated incidence of cardiac arrest, our figure of 1.4 per 10,000 incidences of anesthesia is similar to that reported by others. 4,6 Self-reporting may also lead to inaccuracies in the data, such as underestimates of the anesthetic concentration at the time of arrest.
Second, the institutions participating in the POCA Registry may not be representative of all institutions providing surgical care to children. Despite the best efforts of the authors, the POCA Registry remains heavily skewed toward university-affiliated institutions and pediatric referral centers, although it is likely that a majority of instances of pediatric anesthesia in North America and elsewhere are delivered in community hospitals. At the same time, it is reasonable to expect that the lessons learned from patterns and profiles of cardiac arrest could be applied to all institutions caring for children.
A final weakness is that the demographic data submitted by participating institutions do not yet include distributions for age and ASA physical status of all patients in the pediatric age group who underwent anesthesia. Without these denominators, incidence figures for age and ASA physical status groups cannot be calculated.
In its first 4 yr of operation, the POCA Registry has gathered 150 cases of anesthesia-related cardiac arrest from a total of 289 cases submitted from 63 North American institutions. Medication-related and cardiovascular causes of arrest were most common. Fifty-five percent of arrests occurred in children younger than 1 yr of age. Severe underlying disease and emergency surgery were the factors most strongly associated with mortality following cardiac arrest. ASA physical status 1–2 patients accounted for one third of all anesthesia-related cardiac arrests. Reviewers regarded cardiovascular depression by halothane to be a frequent cause of arrest in this group.
The authors thank the institutional representatives who participated in the POCA Registry and submitted cases for review. Their identities remain anonymous for the purpose of confidentiality. The authors also thank John Campos and Pauline Cooper for their help with data entry and management, and Nikki Louis, Kim Louis, and Karen Taylor for manuscript preparation.
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References

1. Beecher HT, Todd DP: A study of the deaths associated with anesthesia and surgery. Ann Surg 1954; 140:2–34

2. Rackow H, Salinitre E, Green L: Frequency of cardiac arrest associated with anesthesia in infants and children. Pediatrics 1961; 28:697–704

3. Ollson G, Hallen B: Cardiac arrest during anaesthesia: A computerized study in 250,543 anaesthetics. Acta Anaesthesia Scand 1988; 32:653–64

4. Tiret L, Nivoche Y, Hatton F, Desmonts J, Vourc’h G: Complications related to anaesthesia in infants and children. Br J Anaesth 1988; 61:263–9

5. Cohen M, Cameron C, Duncan P: Pediatric anesthetic morbidity and mortality in the perioperative period. Anesth Analg 1990; 70:160–7

6. Keenan R, Boyan CP: Cardiac arrest due to anesthesia: A study of incidence and causes. JAMA 1985; 253:2373–7

7. Morray J, Geiduschek J, Caplan R, Posner K, Gild W, Cheney FW: A comparison of pediatric and adult anesthesia malpractice claims. A nesthesiology 1993; 78:461–7

8. Brunner E: Analysis of anesthesiology mishaps: The National Association of Insurance Commissioners’ Closed Claims Study. Int Anesthesiol Clin 1984; 22:17–30

9. Posner KL, Sampson PD, Caplan RA, Ward RJ, Cheney FW: Measuring interrater reliability among multiple raters: An example of methods for nominal data. Stat Med 1990; 9:1103–15

10. Lerman J, Robinson S, Willis M, Gregory G: Anesthetic requirement for halothane in young children 0-1 months and 1-6 months of age. A nesthesiology 1983; 59:421–4

11. Murray D, Forbes R, Mahoney L: Comparative hemodynamic depression of halothane versus isoflurane in neonates and infants: An echocardiographic study. Anesth Analg 1992; 74:329–37

12. Lerman J, Sikich N, Kleinman S, Yentis S: The pharmacology of sevoflurane in infants and children. A nesthesiology 1994; 80:814–24

13. Johannesson G, Floren M, Lindahl G: Sevoflurane for ENT surgery in children. Acta Anaesthesiol Scand 1995; 39:546–50

14. Wodey E, Pladys P, Copin C, Lucas M, Chaumont A, Carre P, LeLong B, Azzis O, Ecoffey C: Comparative hemodynamic depression of sevoflurane versus halothane in infants. A nesthesiology 1997; 87:795–800

15. Holzman R, van der Velde M, Kaus S, Body S, Colan S, Sullivan L, Soriano S: Sevoflurane depresses myocardial contractility less than halothane during induction of anesthesia in children. A nesthesiology 1996; 85:1260–70

16. Mitchell, ME: Local anesthetic toxic effects, Complications in Anesthesia. Edited by JL Atlee. Philadelphia, WB Saunders, 1999, p 253

17. Salem M, Bennett E, Schweiss J, Baraka A, Dalal F, Collins V: Cardiac arrest related to anesthesia: Contributing factors in infants and children. JAMA 1975; 233:238–41

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Appendix A
Definitions of Mechanisms of Cardiac Arrest
1. Cardiovascular events
• Transfusion reaction: Administration of appropriately matched blood followed by a transfusion reaction to the blood.
• Wrong blood administered: Administration of blood not intended for the patient.
• Hemorrhage: Inability to adequately replace blood loss or arrest due to metabolic consequence of rapid or massive transfusion (e.g., hyperkalemia, hypocalcemia).
• Other possible causes not explicitly defined: Inadequate or inappropriate fluid therapy, electrolyte imbalance, pulmonary embolism, arrhythmia, septic shock, air embolus, failure to wean from cardiopulmonary bypass, and early postbypass cardiac failure.
• Presumed cardiovascular cause, unclear etiology: Cause of event could not be determined, but appeared to be cardiovascular.
2. Medication-related events
• Administration of a drug that was not prescribed, indicated or intended; administration of inappropriate dose of a drug that was intended; syringe or vial swaps; administration of. appropriate drug and dose followed by abnormal response in the patient
• Cardiac arrest as a response to an inhaled anesthetic agent was defined as arrest preceded by evidence of cardiovascular depression during administration of a potent inhaled agent in the absence of hypoxemia, airway obstruction, or equipment problems.
• Intravenous injection of local anesthetic was defined as signs of local anesthetic toxicity (arrhythmia, cardiovascular collapse, or seizures) occurring within 1–2 min of injection of local anesthetic medication.
3. Respiratory events
• Airway obstruction: Obstruction of the patient’s airway from physiologic conditions such as tumors, tracheal stenosis, or laryngospasm diagnosed by physical examination or capnography. Kinking of the endotracheal tube was listed under Equipment Problems.
• Esophageal intubation: Placement of endotracheal tube in esophagus that was not detected within 6 breaths.
• Inadvertent extubation: Inadvertent removal or dislodgment of endotracheal tube.
• Premature extubation: Purposeful removal of endotracheal tube, with subsequent loss of airway patency, regardless of whether appropriate indications for extubation were present.
• Pneumothorax: Pneumothorax specified as the initial event leading to cardiac arrest rather than as a complication of resuscitation.
• Inadequate ventilation: Clinically excessive hypercarbia with respiratory acidosis.
• Inadequate oxygenation: Hypoxemia resulting from failure of the respiratory system.
• Difficult intubation: Difficulty encountered in attempting to place endotracheal tube into the patient’s airway, without specification of number of attempts.
• Aspiration: Passage of gastric contents or other fluids or solid materials into the airway.
• Inadequate fraction of inspired oxygen: Inadequate fraction of inspired oxygen for the maintenance of systemic oxygenation.
• Bronchospasm: Wheezing with need for increased airway pressure, inspired oxygen concentration, or both.
• Presumed respiratory cause, unclear etiology: Cause of event could not be determined, but appeared to be respiratory.
4. Equipment problems
• Equipment misuse (human fault or error associated with preparation, maintenance, or deployment of a medical device) and equipment malfunction despite appropriate maintenance and previous uneventful use.
5. Unknown
• Cause of arrest could not be determined.
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Appendix B
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Appendix C
Definitions for Categories of Impact of Anesthesia on Genesis of Cardiac Arrest
Anesthesia-related: Anesthesia personnel or the anesthetic process played at least some role (ranging from minor to total) in the genesis of cardiac arrest. A single cause for arrest might or might not be known. Cases in which cardiac arrest might have resulted from the failure of anesthesia personnel to provide appropriate consultative advice were included in this category.
Not anesthesia-related: The cause of arrest was known and related entirely to underlying patient disease or to the surgical process. Anesthesia personnel or the anesthetic process did not contribute, even to a minor degree.
Unknown: The cause of the arrest could not be determined or the role of anesthesia personnel or the anesthetic process could not be assessed in the genesis of cardiac arrest.
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Pediatric Anesthesia
Cardiac arrest at induction of anesthesia in a child with undiagnosed right-ventricular dependent coronary circulation: a case report
Brown, TA; Mossad, E; Motta, P
Pediatric Anesthesia, 16(): 1179-1183.
10.1111/j.1460-9592.2006.01958.x
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Annales Francaises D Anesthesie Et De Reanimation
Perioperative analgesia with continuous peripheral nerve blocks in children
Dadure, C; Capdevila, X
Annales Francaises D Anesthesie Et De Reanimation, 26(2): 136-144.
10.1016/j.annfar.2006.10.016
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Regional Anesthesia and Pain Medicine
Comparison of heart rate response to an epinephrine test dose and painful stimulus in children during sevoflurane anesthesia: Heart rate variability and beat-to-beat analysis
Wodey, E; Senhadji, L; Bansard, JY; Terrier, A; Carre, F; Ecoffey, C
Regional Anesthesia and Pain Medicine, 28(5): 439-444.
10.1016/S1098-7339(03)00220-7
CrossRef
Resuscitation
The effect of global hypoxia on myocardial function after successful cardiopulmonary resuscitation in a laboratory model
McCaul, CL; McNamara, P; Engelberts, D; Slorach, C; Hornberger, LK; Kavanagh, BP
Resuscitation, 68(2): 267-275.
10.1016/j.resuscitation.2005.06.018
CrossRef
Drugs
Induction of anaesthesia - A guide to drug choice
Nathan, N; Odin, I
Drugs, 67(5): 701-723.

Anesthesia and Analgesia
Emergency tracheal intubation: Complications associated with repeated laryngoscopic attempts
Mort, TC
Anesthesia and Analgesia, 99(2): 607-613.
10.1213/01.ANE.0000122825.04923.15
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British Journal of Anaesthesia
Perioperative cardiac arrest: a study of 53718 anaesthetics over 9 yr from a Brazilian teaching hospital
Braz, LG; Modolo, NSP; do Nascimento, P; Bruschi, BAM; Castiglia, YMM; Ganem, EM; de Carvalho, LR; Braz, JRC
British Journal of Anaesthesia, 96(5): 569-575.
10.1093/bja/ael065
CrossRef
Annales Francaises D Anesthesie Et De Reanimation
Oxygen arterial desaturation and upholding the oxygenation during intubation - Question 2
Bourgain, JL; Chastre, J; Combes, X; Orliaguet, G
Annales Francaises D Anesthesie Et De Reanimation, 27(1): 15-25.
10.1016/j.annfar.2007.10.023
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Anaesthesia and Intensive Care
An audit of perioperative cardiac arrests in a Southeast Asian university teaching hospital over 15 years
Ahmed, A; Ali, M; Khan, FA; Khan, MU
Anaesthesia and Intensive Care, 36(5): 710-716.

Cardiology in the Young
Anaesthetic complications associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease
Vener, DF; Tirotta, CF; Andropoulos, D; Barach, P
Cardiology in the Young, 18(): 271-281.
10.1017/S104795110800303X
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Anaesthesia and Intensive Care
The frequency of and indications for general anaesthesia in children in Western Australia 2002-2003
Sims, C; Stanley, B; Milne, E
Anaesthesia and Intensive Care, 33(5): 623-628.

Pediatric Anesthesia
Sevoflurane 12% versus 8% raises concerns - Author's reply
Chawathe, M; Zatman, T; Hall, J; Gildersleve, C; Jones, R; Wilkes, A; Aguilera, I; Armstrong, T
Pediatric Anesthesia, 16(5): 602.
10.1111/j.1460-9592.2006.01892.x
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Anaesthesia
Intubation of infants with Pierre Robin syndrome: the use of the paraglossal approach combined with a gum-elastic bougie in six consecutive cases
Semjen, F; Bordes, M; Cros, AM
Anaesthesia, 63(2): 147-150.
10.1111/j.1365-2044.2007.05097.x
CrossRef
Anesthesia and Analgesia
Factors Associated with Unanticipated Day of Surgery Deaths in Department of Veterans Affairs Hospitals
Bishop, MJ; Souders, JE; Peterson, CM; Henderson, WG; Domino, KB
Anesthesia and Analgesia, 107(6): 1924-1935.
10.1213/ane.0b013e31818af8f3
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Pediatric Anesthesia
Anesthetic-induced neurotoxicity of the neonate: time for clinical guidelines?
Sanders, RD; Davidson, A
Pediatric Anesthesia, 19(): 1141-1146.
10.1111/j.1460-9592.2009.03141.x
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Paediatric Anaesthesia
Searching for the Holy Grail: measuring risk in paediatric anaesthesia
Van der Walt, JH
Paediatric Anaesthesia, 11(6): 637-641.

Journal of Surgical Oncology
Nature and prevention of errors in anesthesiology
Heine, MF; Lake, CL
Journal of Surgical Oncology, 88(3): 143-152.
10.1002/jso.20124
CrossRef
Annals of Otology Rhinology and Laryngology
Infant cochlear implantation and anesthetic risk
Young, NM
Annals of Otology Rhinology and Laryngology, 111(5): 49-51.

Pediatrics
Patient safety events during pediatric hospitalizations
Miller, MR; Elixhauser, A; Zhan, CL
Pediatrics, 111(6): 1358-1366.

Lancet
Perioperative management and monitoring in anaesthesia
Buhre, W; Rossaint, R
Lancet, 362(): 1839-1846.

Annales Francaises D Anesthesie Et De Reanimation
Risks in paediatric anaesthesia
Murat, I; Humblot, A; Girault, L
Annales Francaises D Anesthesie Et De Reanimation, 28(): 666-670.
10.1016/j.annfar.2009.06.013
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Pediatric Anesthesia
An update on the etiology and prevention of anesthesia-related cardiac arrest in children
Mason, LJ
Pediatric Anesthesia, 14(5): 412-416.

Neuroimaging Clinics of North America
Pediatric neuroanesthesia
Soriano, SG; Eldredge, EA; Rockoff, MA
Neuroimaging Clinics of North America, 17(2): 259-+.
10.1016/j.nic.2007.03.010
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Notfall & Rettungsmedizin
Anesthesia-related cardiac arrest in children
Mitterlechner, T
Notfall & Rettungsmedizin, 11(1): 57-58.
10.1007/s10049-007-0972-x
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Archives De Pediatrie
How to assess the correct position of intraosseous access? A case report
Semjen, F; Dobremez, E; Bordes, M
Archives De Pediatrie, 16(9): 1298-1300.
10.1016/j.arcped.2009.05.010
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Pediatric Anesthesia
Anesthetic management of children with pulmonary arterial hypertension
Friesen, RH; Williams, GD
Pediatric Anesthesia, 18(3): 208-216.
10.1111/j.1460-9592.2008.02419.x
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Journal of Pediatric Surgery
Neonatal repair of cleft lip: a decision-making protocol
Galinier, P; Salazard, B; Deberail, A; Vitkovitch, F; Caovan, C; Chausseray, G; Acar, P; Sami, K; Guitard, J; Smail, N
Journal of Pediatric Surgery, 43(4): 662-667.
10.1016/j.jpedsurg.2007.12.006
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Anesthesia and Analgesia
Cardiac Arrest in the Neonate During Laparoscopic Surgery
Lalwani, K; Aliason, I
Anesthesia and Analgesia, 109(3): 760-762.
10.1213/ane.0b013e3181adc6f9
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Pediatric Anesthesia
Anesthesia and perioperative medical management of children with spinal muscular atrophy
Graham, RJ; Athiraman, U; Laubach, AE; Sethna, NF
Pediatric Anesthesia, 19(): 1054-1063.
10.1111/j.1460-9592.2009.03055.x
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Indoor and Built Environment
Gas chromatographic determination of halothane levels in hospital operating theatres
Culea, M; Nicoara, S; Nica, NA; Gherman, C
Indoor and Built Environment, 12(): 125-129.
10.1177/142032603032440
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Anaesthesia
Consent and anaesthetic risk
Jenkins, K; Baker, AB
Anaesthesia, 58(): 962-984.

British Journal of Anaesthesia
Unusual presentation of long QT syndrome
Cucchiaro, G; Rhodes, LA
British Journal of Anaesthesia, 90(6): 804-807.
10.1093/bja/aeg138
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Pediatric Anesthesia
Sevoflurane (12% and 8%) inhalational induction in children
Chawathe, M; Zatman, T; Hall, JE; Gildersleve, C; Jones, RM; Wilkes, AR; Aguilera, IM; Armstrong, TS
Pediatric Anesthesia, 15(6): 470-475.
10.1111/j.1460-9592.2005.01478.x
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Pediatric Anesthesia
The postoperative cardiovascular arrest of a 5-year-old male: an initial presentation of Duchenne's muscular dystrophy
Girshin, M; Mukherjee, J; Clowney, R; Singer, LP; Wasnick, J
Pediatric Anesthesia, 16(2): 170-173.
10.1111/j.1460-9592.2005.01698.x
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Samj South African Medical Journal
Fifty years of paediatric anaesthesia - new approaches to an old technique
Bosenberg, AT; Ing, RJ; Thomas, JM
Samj South African Medical Journal, 96(9): 880-+.

Anesthesia and Analgesia
Victims of our own success or quo vadis pediatric anesthesia?
Nichols, DG; Yaster, M
Anesthesia and Analgesia, 104(2): 255-257.
10.1213/01.ane.0000253549.28893.bc
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Anesthesia and Analgesia
Perioperative complications in children with pulmonary hypertension undergoing noncardiac surgery or cardiac catheterization
Carmosino, MJ; Friesen, RH; Doran, A; Ivy, DD
Anesthesia and Analgesia, 104(3): 521-527.
10.1213/01.ane.0000255732.16057.1c
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Anasthesiologie & Intensivmedizin
Anaesthesia induction in children
Becke, K; Landsleitner, B; Strauss, J
Anasthesiologie & Intensivmedizin, 51(): 347-+.

Paediatric Anaesthesia
Do we need a new muscle relaxant in paediatrics?
Goudsouzian, N
Paediatric Anaesthesia, 13(1): 1-2.

Anasthesiologie & Intensivmedizin
Tiny patients - big problems
Johr, M
Anasthesiologie & Intensivmedizin, 46(): 358-370.

Pediatric Anesthesia
Perioperative cardiac arrest and its mortality in children. A 9-year survey in a Brazilian tertiary teaching hospital
Braz, LG; Braz, JRC; Modolo, NSP; Do Nascimento, P; Brushi, BAM; De Carvalho, LR
Pediatric Anesthesia, 16(8): 860-866.
10.1111/j.1460-9592.2006.01876.x
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Journal of Aapos
Simultaneous bilateral intraocular surgery in children
Nallasamy, S; Davidson, SL; Kuhn, I; Mills, MD; Forbes, BJ; Anninger, WV; Stricker, PA
Journal of Aapos, 14(1): 15-19.
10.1016/j.jaapos.2009.10.014
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Pakistan Journal of Medical Sciences
Postoperative Cardiac Arrest Due to Cardiac Surgery Complications
Ebadi, A; Ramezani, A; Rahim, F; Afraee, N
Pakistan Journal of Medical Sciences, 26(1): 43-48.

Anesthesia and Analgesia
The frequency of anesthesia-related cardiac arrests in patients with congenital heart disease undergoing cardiac surgery
Odegard, KC; DiNardo, JA; Kussman, BD; Shukla, A; Harrington, J; Casta, A; McGowan, FX; Hickey, PR; Bacha, EA; Thiagarajan, RR; Laussen, PC
Anesthesia and Analgesia, 105(2): 335-343.
10.1213/01.ane.0000268498.68620.39
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Seminars in Pediatric Surgery
Outcomes of pediatric anesthesia
Hoffman, GM
Seminars in Pediatric Surgery, 17(2): 141-151.
10.1053/j.sempedsurg.2008.02.010
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Journal of Pediatric Surgery
The optimal approach for management of metachronous hernias in children: A decision analysis
Burd, RS; Heffington, SH; Teague, JL
Journal of Pediatric Surgery, 36(8): 1190-1195.

Indoor and Built Environment
Selected ion monitoring - Gas chromatography/mass spectrometry determination of halothane fumes in operating theatres
Nicoara, S; Culea, M; Nica, AN; Culea, E; Cozar, O
Indoor and Built Environment, 14(5): 405-410.
10.1177/1420326X05056857
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Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie
Anaesthesia in thorax-surgical attacks in childhood - Introduction and overview
Hachenberg, T
Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie, 41(): 640-641.

Anesthesia and Analgesia
Anesthesia-Related Cardiac Arrest in Children with Heart Disease: Data from the Pediatric Perioperative Cardiac Arrest (POCA) Registry
Ramamoorthy, C; Haberkern, CM; Bhananker, SM; Domino, KB; Posner, KL; Campos, JS; Morray, JP
Anesthesia and Analgesia, 110(5): 1376-1382.
10.1213/ANE.0b013e3181c9f927
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Paediatric Anaesthesia
Perioperative anaesthetic morbidity in children: a database of 24,165 anaesthetics over a 30-month period
Murat, I; Constant, I; Maud'huy, H
Paediatric Anaesthesia, 14(2): 158-166.

Pediatrics
Preparing a 3-year-old and his parents for an elective surgery (Reprinted from J Dev Behav Pediatr, vol 23, pg 37, 2002)
Stein, MT; Rothstein, P; Kennell, JH; Kearney, R; Farris, D; Wessel, M
Pediatrics, 114(5): 1414-1418.
10.1542/peds.2004-1721D
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Clinical Therapeutics
Anesthesia and analgesia during and after surgery in neonates
Berde, CB; Jaksic, T; Lynn, AM; Maxwell, LG; Soriano, SG; Tibboel, D
Clinical Therapeutics, 27(6): 900-921.
10.1016/j.clinthera.2005.06.020
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Pediatric Anesthesia
Use of low-dose rocuronium for intubation of children during volunteer surgery abroad
Politis, GD; Brill, J; Jones, J
Pediatric Anesthesia, 15(8): 648-652.
10.1111/j.1460-9592.2004.01519.x
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Current Problems in Surgery
Care of the Pediatric Cardiac Surgery Patient-Part 1
[Anon]
Current Problems in Surgery, 47(3): 185-250.
10.1067/j.cpsurg.2009.11.006
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Anesthesia and Analgesia
Hyperkalemic cardiac arrest after cardiopulmonary bypass in a child with unsuspected Duchenne muscular dystrophy
Nathan, A; Ganesh, A; Godinez, RI; Nicolson, SC; Greeley, WJ
Anesthesia and Analgesia, 100(3): 672-674.
10.1213/01.ANE.0000146533.21771.2F
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Surgical Clinics of North America
Neonatal and childhood perioperative considerations
Burd, RS; Mellender, SJ; Tobias, JD
Surgical Clinics of North America, 86(2): 227-+.
10.1016/j.suc.2005.12.010
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Anesthesia and Analgesia
An update on pediatric anesthesia liability: A closed claims analysis
Jimenez, N; Posner, KL; Cheney, FW; Caplan, RA; Lee, LA; Domino, KB
Anesthesia and Analgesia, 104(1): 147-153.
10.1213/01.ane.0000246813.04771.03
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Anesthesia and Analgesia
When assessing what we know we don't know is not enough: Another perspective on pediatric outcomes
Davis, PJ
Anesthesia and Analgesia, 105(2): 301-303.
10.1213/01.ane.0000268711.86620.76
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Anesthesia and Analgesia
Pitfalls and problems in pediatric anesthesia
Mason, LJ
Anesthesia and Analgesia, 94(3): 70-76.

Paediatric Anaesthesia
Bradycardia with sevoflurane induction in patients with trisomy 21
Roodman, S; Bothwell, M; Tobias, JD
Paediatric Anaesthesia, 13(6): 538-540.

Anaesthesia and Intensive Care
Use of odds ratios on anaesthesia related studies
Ho, KM; Marshall, RJ; Walters, S
Anaesthesia and Intensive Care, 31(4): 392-395.

Signa Vitae
Perioperative Cardiac Arrests
Sprung, J; Flick, RP; Gleich, SJ; Weingarten, TN
Signa Vitae, 3(2): 8-12.

Journal of Plastic Reconstructive and Aesthetic Surgery
The role of surgery in the management of congenital melanocytic naevi in children: a perspective from Great Ormond Street Hospital
Kinisler, V; Butstrode, N
Journal of Plastic Reconstructive and Aesthetic Surgery, 62(5): 595-601.
10.1016/j.bjps.2008.12.016
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Quality & Safety in Health Care
Unexpected cardiac arrest among children during surgery: a North American registry to elucidate the incidence and causes of anesthesia related cardiac arrest
Posner, KL; Geiduschek, J; Haberkern, CM; Ramamoorthy, C; Hackell, A; Morray, JP
Quality & Safety in Health Care, 11(3): 252-257.

Annales Francaises D Anesthesie Et De Reanimation
Morbidity and mortality linked to paediatric anaesthesia in the Maghreb
Hmamouchi, B; Nejmi, S; Benkhalifa, S; Dehdouh, A; Chlilek, A
Annales Francaises D Anesthesie Et De Reanimation, 28(): 671-673.
10.1016/j.annfar.2009.06.010
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Clinics
Mortality in Anesthesia: A Systematic Review
Braz, LG; Braz, DG; da Cruz, DS; Fernandes, LA; Modolo, NSP; Brazi, JRC
Clinics, 64(): 999-1006.
10.1590/S1807-59322009001000011
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Archives of Pediatrics & Adolescent Medicine
Risks of Propofol Sedation/Anesthesia for Imaging Studies in Pediatric Research Eight Years of Experience in a Clinical Research Center
Kiringoda, R; Thurm, AE; Hirschtritt, ME; Koziol, D; Wesley, R; Swedo, SE; O'Grady, NP; Quezado, ZMN
Archives of Pediatrics & Adolescent Medicine, 164(6): 554-560.

Anesthesia and Analgesia
The safety and efficacy of spinal anesthesia for surgery in infants: The Vermont infant spinal registry
Williams, RK; Adams, DC; Aladjem, EV; Kreutz, JM; Sartorelli, KH; Vane, DW; Abajian, JC
Anesthesia and Analgesia, 102(1): 67-71.
10.1213/01.ANE.0000159162.86033.21
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Childs Nervous System
Anesthesia for epilepsy surgery in children
Soriano, SG; Bozza, P
Childs Nervous System, 22(8): 834-843.
10.1007/s00381-006-0121-8
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Pediatric Anesthesia
Specialist training in pediatric anesthesia - the Scandinavian approach
Hansen, TG
Pediatric Anesthesia, 19(5): 428-433.
10.1111/j.1460-9592.2009.02932.x
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Paediatric Anaesthesia
Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore
Tay, CLM; Tan, GM; Ng, SBA
Paediatric Anaesthesia, 11(6): 711-718.

Quality & Safety in Health Care
Crisis management during anaesthesia: cardiac arrest
Runciman, WB; Morris, RW; Watterson, LM; Williamson, JA; D Paix, A
Quality & Safety in Health Care, 14(3): -.
ARTN e14
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Childs Nervous System
Anesthesiological and intensive care considerations in children undergoing extensive cerebral excision procedure for congenital epileptogenic lesions
Pietrini, D; Zanghi, F; Pusateri, A; Tosi, F; Pulitano, S; Piastra, M
Childs Nervous System, 22(8): 844-851.
10.1007/s00381-006-0153-0
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Pediatric Anesthesia
Cardiac rhythm and left ventricular function of infants at 1 MAC sevoflurane and halothane
Saudan, S; Beghetti, M; Spahr-Schopfer, I; Mamie, C; Habre, W
Pediatric Anesthesia, 17(6): 540-546.
10.1111/j.1460-9592.2006.02174.x
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Archives De Pediatrie
Focusing of inguinal hernia in children
Galinier, P; Bouali, O; Juricic, M; Smail, N
Archives De Pediatrie, 14(4): 399-403.
10.1016/S0929-693X(07)00028-0
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Anesthesia and Analgesia
Anesthesia-related cardiac arrest in children: Update from the Pediatric Perioperative Cardiac Arrest Registry
Bhananker, SM; Ramamoorthy, C; Geiduschek, JM; Posner, KL; Domino, KB; Haberkern, CM; Campos, JS; Morray, JP
Anesthesia and Analgesia, 105(2): 344-350.
10.1213/01.ane.0000268712.00756.dd
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Pediatric Anesthesia
Perioperative cardiac arrests in children at a university teaching hospital of a developing country over 15 years
Ahmed, A; Ali, M; Khan, M; Khan, F
Pediatric Anesthesia, 19(6): 581-586.
10.1111/j.1460-9592.2009.02992.x
CrossRef
Anesthesiology
Bringing light to tbe dark side
Rothstein, P
Anesthesiology, 93(1): 1-+.

Archives De Pediatrie
The anaesthetic risk: information for pediatricians
Hamza, J; Simon, L; de Saint-Blanquat, L; Bojan, M; Yung, F
Archives De Pediatrie, 10(): 220S-222S.

Laryngoscope
Cochlear Implantation in Infants: Special Surgical and Medical Aspects
Migirov, L; Carmel, E; Kronenberg, J
Laryngoscope, 118(): 2024-2027.
10.1097/MLG.0b013e3181806402
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Saudi Medical Journal
Intramuscular ketamine for prevention of postanesthesia shivering in children
Zahra, FA; Abudallah, HM; Shabana, RI; Abdulmageed, WM; Abdulrazik, SI; Nassar, AM
Saudi Medical Journal, 29(9): 1255-1259.

Journal of Clinical Anesthesia
Successful and safe delivery of anesthesia and perioperative care for children with complex special health care needs
Graham, RJ; Wachendorf, MT; Burns, JP; Mancuso, TJ
Journal of Clinical Anesthesia, 21(3): 165-172.
10.1016/j.jclinane.2008.06.033
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International Journal of Pediatric Otorhinolaryngology
Diagnostic challenges and safety considerations in cochlear implantation under the age of 12 months
Vlastarakos, PV; Candiloros, D; Papacharalampous, G; Tavoulari, E; Kampessis, G; Mochloulis, G; Nikolopoulos, TP
International Journal of Pediatric Otorhinolaryngology, 74(2): 127-132.
10.1016/j.ijporl.2009.10.023
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American Journal of Health-System Pharmacy
Considerations in selecting an inhaled anesthetic agent: Case studies
Golembiewski, J
American Journal of Health-System Pharmacy, 61(): S10-S17.

Pediatric Anesthesia
Oxygen - elixir of life or Trojan horse? Part 2: oxygen and neonatal anesthesia
van der Walt, J
Pediatric Anesthesia, 16(): 1205-1212.
10.1111/j.1460-9592.2006.02073.x
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Singapore Medical Journal
Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetics
Wan, S; Siow, YN; Lee, SM; Ng, A
Singapore Medical Journal, 54(2): 69-74.

Pediatric Anesthesia
Pediatric cardiopulmonary arrest in the postanesthesia care unit: analysis of data from the American Heart Association Get With The Guidelines (R)-Resuscitation registry
Christensen, R; Voepel-Lewis, T; Lewis, I; Ramachandran, SK; Malviya, S
Pediatric Anesthesia, 23(6): 517-523.
10.1111/pan.12154
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Journal of Pediatric Surgery
Conservative treatment for complex neonatal ovarian cysts: A long-term follow-up analysis
Cesca, E; Midrio, P; Boscolo-Berto, R; Snijders, D; Salvador, L; D'Antona, D; Zanon, GF; Gamba, P
Journal of Pediatric Surgery, 48(3): 510-515.
10.1016/j.jpedsurg.2012.07.067
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Pediatric Anesthesia
Interventions guided by analysis of quality indicators decrease the frequency of laryngospasm during pediatric anesthesia
Mc Donnell, C
Pediatric Anesthesia, 23(7): 579-587.
10.1111/pan.12070
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Comprehensive Physiology
Effects of Anesthetics, Sedatives, and Opioids on Ventilatory Control
Stuth, EAE; Stucke, AG; Zuperku, EJ
Comprehensive Physiology, 2(4): 2281-2367.
10.1002/cphy.c100061
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Anesthesiology
Did Anesthetics Trigger Cardiac Arrests in Patients with Occult Myopathies?
Larach, MG; Rosenberg, H; Gronert, GA; Allen, GC
Anesthesiology, 94(5): 933-934.

Anesthesiology
Anesthesiology Residents' Performance of Pediatric Resuscitation during a Simulated Hyperkalemic Cardiac Arrest
Howard-Quijano, KJ; Stiegler, MA; Huang, YM; Canales, C; Steadman, RH
Anesthesiology, 112(4): 993-997.
10.1097/ALN.0b013e3181d31fbe
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Anesthesiology
Massive Inhalation of Desflurane due to Vaporizer Dysfunction
Geffroy, J; Gentili, ME; Le Pollès, R; Triclot, P
Anesthesiology, 103(5): 1096-1098.

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Anesthesiology
Assessing Pediatric Anesthesia Practices for Volunteer Medical Services Abroad
Fisher, QA; Nichols, D; Stewart, FC; Finley, GA; Magee, WP; Nelson, K
Anesthesiology, 95(6): 1315-1322.

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Anesthesiology
Pediatric Perioperative Cardiac Arrest: In Search of Definition(s)
Morray, JP; Posner, K
Anesthesiology, 106(2): 207-208.

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Anesthesiology
Perioperative Cardiac Arrests in Children between 1988 and 2005 at a Tertiary Referral Center: A Study of 92,881 Patients
Flick, RP; Sprung, J; Harrison, TE; Gleich, SJ; Schroeder, DR; Hanson, AC; Buenvenida, SL; Warner, DO
Anesthesiology, 106(2): 226-237.

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Anesthesiology
Anesthesia-related Cardiac Arrest in Children
Coté, CJ
Anesthesiology, 94(5): 933.

Anesthesiology
Predictors of Survival following Cardiac Arrest in Patients Undergoing Noncardiac Surgery: A Study of 518,294 Patients at a Tertiary Referral Center
Sprung, J; Warner, ME; Contreras, MG; Schroeder, DR; Beighley, CM; Wilson, GA; Warner, DO
Anesthesiology, 99(2): 259-269.

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Anesthesiology
Anesthestic-related Cardiac Arrest and Its Mortality: A Report Covering 72,959 Anesthetics over 10 Years from a US Teaching Hospital
Ullrich, FA; Anderson, JR; Newland, MC; Ellis, SJ; Lydiatt, CA; Peters, KR; Tinker, JH; Romberger, DJ
Anesthesiology, 97(1): 108-115.

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Anesthesiology
The Upper Respiratory Tract Infection (URI) Dilemma: Fear of a Complication or Litigation?
Coté, CJ
Anesthesiology, 95(2): 283-285.

Current Opinion in Critical Care
Cardiac arrest during anesthesia
Zuercher, M; Ummenhofer, W
Current Opinion in Critical Care, 14(3): 269-274.
10.1097/MCC.0b013e3282f948cd
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Ear and Hearing
Communication Development in Children Who Receive the Cochlear Implant Younger than 12 Months: Risks versus Benefits
Dettman, SJ; Pinder, D; Briggs, RJ; Dowell, RC; Leigh, JR
Ear and Hearing, 28(2): 11S-18S.
10.1097/AUD.0b013e31803153f8
PDF (429) | CrossRef
Ear and Hearing
An Exploratory Look at Pediatric Cochlear Implantation: Is Earliest Always Best?
Holt, RF; Svirsky, MA
Ear and Hearing, 29(4): 492-511.
10.1097/AUD.0b013e31816c409f
PDF (2643) | CrossRef
European Journal of Anaesthesiology (EJA)
Just a grommet: cardiac arrest in a healthy adolescent
van Woerkens, EC; Megens, JH
European Journal of Anaesthesiology (EJA), 25(10): 860&hyhen;861.
10.1017/S0265021508004018
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European Journal of Anaesthesiology (EJA)
The performance of Bispectral Index in children during equi‐MAC halothane vs. sevoflurane anaesthesia
Taivainen, T; Klockars, J; Hiller, A; Wennervirta, J; van Gils, MJ; Suominen, P
European Journal of Anaesthesiology (EJA), 25(11): 933&hyhen;939.
10.1017/S0265021508004845
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European Journal of Anaesthesiology (EJA)
Paediatric perioperative cardiac arrest and its mortality: database of a 60-month period from a tertiary care paediatric centre
Bharti, N; Batra, YK; Kaur, H
European Journal of Anaesthesiology (EJA), 26(6): 490-495.
10.1097/EJA.0b013e328323dac0
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Journal of Pediatric Hematology/Oncology
Initial Bone Marrow Aspiration in Childhood Idiopathic Thrombocytopenia: Decision Analysis
Klaassen, RJ; Doyle, JJ; Krahn, MD; Blanchette, VS; Naglie, G
Journal of Pediatric Hematology/Oncology, 23(8): 511-518.

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Journal of Developmental & Behavioral Pediatrics
Preparing a 3 Year Old and His Parents for an Elective Surgery

Journal of Developmental & Behavioral Pediatrics, 22(6): 425-429.

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Pediatric Critical Care Medicine
Anesthesia considerations for children with pulmonary hypertension
Shukla, AC; Almodovar, MC
Pediatric Critical Care Medicine, 11(): S70-S73.
10.1097/PCC.0b013e3181c76c6e
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Pediatric Critical Care Medicine
Therapeutic applications and uses of inhalational anesthesia in the pediatric intensive care unit*
Tobias, JD
Pediatric Critical Care Medicine, 9(2): 169-179.
10.1097/PCC.0b013e31816688ef
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Southern Medical Journal
Anesthesia: Looking Back at the Last Century and Forward to the Next
Tobias, JD
Southern Medical Journal, 99(3): 320-322.
10.1097/01.smj.0000208101.15847.a7
PDF (42) | CrossRef
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Keywords:
Anesthetic complications; outcomes; pediatric.

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