الفهرس 
Preresuscitation preparation/ PreventionOnly 14 pages are availabe for public view
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Abstract
Summary
Pediatric perioperative life support requires teamwork from nurses, surgeons, and anesthesiologists who may work together infrequently and may not have the opportunity to practice or engage in resuscitation efforts together. It is important in this setting to understand the likely causes of perioperative arrest in children, how to prepare for them, what skills are needed, what resources are available, and how to practice and maintain these infrequently used skills. )Apfelbaum et al., 2013)
Typical PALS courses may emphasize prehospital management without covering information that pertains to perioperative resuscitation. Anesthesiologists should take the responsibility to understand and share the knowledge needed to maximize pediatric perioperative resuscitation, such as effective monitoring of CPR efforts and management of anesthetic overdose, laryngospasm, hyperkalemia, local anesthetic toxicity, VP shunt complications, Williams syndrome, prolonged QT syndrome, arrest in the prone position, and the institution of ECLS.
The anesthesiologist is in an optimum position to incorporate (1) the typical PALS training, including universal resuscitation techniques and medication
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administration; (2) expertise in airway management, pharmacology, physiology, and technology; and (3) the knowledge presented here, in specific perioperative resuscitation situations. By incorporating all 3 aspects, anesthesiologists can best help direct perioperative resuscitation efforts when 1 of these infrequent and terrifying scenarios occurs during the care of a child. (Atkins et al., 2009)
Resuscitation is a complex skill performed under stressful conditions. The complexity and stress encountered during a pediatric resuscitation can contribute to both a decrease in effectiveness and an increase in errors. To address these concerns, one can develop and train a team to have designated roles and responsibilities and improved communication skills. (Bharti et al., 2009)
The usual resuscitation begins with a call for help in the form of “Any anesthesiologist to operating room….” Ideally, after this call for help, the appropriate additional staff would arrive and be assigned roles for resuscitation. Often, however, more personnel arrive than are needed, and neither a team leader nor team member roles are assigned. The noisy chaos that follows can make an already difficult situation worse. Practicing who should respond to a call for help, designating a team leader, and assigning roles for the resuscitation team can help prevent this chaotic situation. (Bhananker et al., 2007)
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The suggested resuscitation roles from AHA PALS training can be modified to make the 6 roles and responsibilities appropriate for OR staff.
The Leader has responsibility for overall management and also for determining an etiology of the arrest. This position may be most appropriate for the anesthesiologist who was monitoring the patient’s physiology before the arrest. The assignment of this role is maintained for the entire resuscitation. The leader should only oversee management and not assume any of the other roles.
The Airway role may be assigned to a second anesthesiologist, if one is available, who can decide whether the airway is adequate and whether hand ventilation is preferable to mechanical ventilation. The team member in this role should also monitor ETCO2 to establish that the airway placement continues to be appropriate and report the saturation and ETCO2 levels to the leader and recorder every 2 minutes or after a sudden change. The person in this role may also be in the ideal position to apply ice to the child’s head if doing so is deemed appropriate. (Cavallone et al., 2013)
The Access/Meds role may be assigned to a surgeon, anesthesiologist, or nurse who will obtain any additional access, IV or IO, and administer medications and fluids as directed by the team leader. The individual in the access
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role should report each medication and post medication flush to both the recorder and leader at the time of administration. Closed-loop communication should be used (recipient repeats the message in a way that shows the sender it was received and understood).
The Monitor/Defibrillator role may be assigned to a surgeon, anesthesiologist, or nurse who notes the child’s rhythm during pauses in compression and administers shocks as needed. Depending on the area involved in the surgery and whether the chest needs to remain sterile, a surgeon who is already scrubbed and remaining sterile may be preferred. (American Heart Association, 2011)
The Compressor role may preferably be assigned to a surgeon who is scrubbed and sterile because he/she may need to maintain a sterile field. As with this role outside the OR, fatigue is a concern, and rotation should occur every 2 minutes, if possible, to maintain the quality of the chest compressions. The compressor needs to be familiar with the 2-thumb encircling technique for infants, prone compressions for prone children, and the use of ETCO2 to monitor the effectiveness of the CPR.
The Recorder role may be assigned to a nurse or anesthesiologist. A more specific recording tool than the anesthesia record would be helpful to track interventions delivered for review by the team and to prompt future interventions at the appropriate time to reduce the chance
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that they are missed or delayed. The recorder should track and announce the 2-minute compressor change and rhythm check, the medications administered and when they are due again, the timing of shocks delivered, and when ECMO should be activated.
Additional roles that are common to arrest situations include a Gofer, who is responsible for delivery of necessary items, Security, who is responsible for controlling the crowd and noise and asking unwanted participants to leave, and a Parental Advocate, who accompanies the child’s parent (if present), explains the team’s efforts, and monitors the parent’s response to the situation. Thecommunication skills described in the AHA PALS training also should be incorporated into the OR environment for pediatric resuscitations. These skills include: clear roles and responsibilities, mutual respect, clear messages, closed-loop communication, knowing (and sharing) one’s limitations, knowledge sharing, constructive intervention, and reevaluation and summarizing. (Schwartz et al., 2011)