51
|
Hayes LW, Dobyns EL, DiGiovine B, Brown AM, Jacobson S, Randall KH, Wathen B, Richard H, Schwab C, Duncan KD, Thrasher J, Logsdon TR, Hall M, Markovitz B. A multicenter collaborative approach to reducing pediatric codes outside the ICU. Pediatrics 2012; 129:e785-91. [PMID: 22351886 DOI: 10.1542/peds.2011-0227] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The Child Health Corporation of America formed a multicenter collaborative to decrease the rate of pediatric codes outside the ICU by 50%, double the days between these events, and improve the patient safety culture scores by 5 percentage points. METHODS A multidisciplinary pediatric advisory panel developed a comprehensive change package of process improvement strategies and measures for tracking progress. Learning sessions, conference calls, and data submission facilitated collaborative group learning and implementation. Twenty Child Health Corporation of America hospitals participated in this 12-month improvement project. Each hospital identified at least 1 noncritical care target unit in which to implement selected elements of the change package. Strategies to improve prevention, detection, and correction of the deteriorating patient ranged from relatively simple, foundational changes to more complex, advanced changes. Each hospital selected a broad range of change package elements for implementation using rapid-cycle methodologies. The primary outcome measure was reduction in codes per 1000 patient days. Secondary outcomes were days between codes and change in patient safety culture scores. RESULTS Code rate for the collaborative did not decrease significantly (3% decrease). Twelve hospitals reported additional data after the collaborative and saw significant improvement in code rates (24% decrease). Patient safety culture scores improved by 4.5% to 8.5%. CONCLUSIONS A complex process, such as patient deterioration, requires sufficient time and effort to achieve improved outcomes and create a deeply embedded culture of patient safety. The collaborative model can accelerate improvements achieved by individual institutions.
Collapse
Affiliation(s)
- Leslie W Hayes
- Department of Pediatrics, Children’s Hospital of Alabama, University of Alabama, Birmingham, AL 35233, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
52
|
Evaluation of quantitative debriefing after pediatric cardiac arrest. Resuscitation 2012; 83:1124-8. [PMID: 22306665 DOI: 10.1016/j.resuscitation.2012.01.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 12/07/2011] [Accepted: 01/16/2012] [Indexed: 12/21/2022]
Abstract
AIM Our primary objective was to describe and determine the feasibility of implementing a care environment targeted pediatric post-cardiac arrest debriefing program. A secondary objective was to evaluate the usefulness of debriefing content items. We hypothesized that a care environment targeted post-cardiac arrest debriefing program would be feasible, well-received, and result in improved self-reported knowledge, confidence and performance of pediatric providers. METHODS Physician-led multidisciplinary pediatric post-cardiac arrest debriefings were conducted using data from CPR recording defibrillators/central monitors followed by a semi-quantitative survey. Eight debriefing content elements divided, a priori, into physical skill (PS) related and cognitive skill (CS) related categories were evaluated on a 5-point Likert scale to determine those most useful (5-point Likert scale: 1=very useful/5=not useful). Summary scores evaluated the impact on providers' knowledge, confidence, and performance. RESULTS Between June 2010 and May 2011, 6 debriefings were completed. Thirty-four of 50 (68%) front line care providers attended the debriefings and completed surveys. All eight content elements were rated between useful to very useful (Median 1; IQR 1-2). PS items scored higher than CS items to improve knowledge (Median: 2 (IQR 1-3) vs. 1 (IQR 0-2); p<0.02) and performance (Median: 2 (IQR 1-3) vs. 1 (IQR 0-1); p<0.01). CONCLUSIONS A novel care environment targeted pediatric post-cardiac arrest pediatric debriefing program is feasible and useful for providers regardless of their participation in the resuscitation. Physical skill related elements were rated more useful than cognitive skill related elements for knowledge and performance.
Collapse
|
53
|
Niebauer JM, White ML, Zinkan JL, Youngblood AQ, Tofil NM. Hyperventilation in pediatric resuscitation: performance in simulated pediatric medical emergencies. Pediatrics 2011; 128:e1195-200. [PMID: 21969287 DOI: 10.1542/peds.2010-3696] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the hypothesis that pediatric resuscitation providers hyperventilate patients via bag-valve-mask (BVM) ventilation during performance of cardiopulmonary resuscitation (CPR), quantify the degree of excessive ventilation provided, and determine if this tendency varies according to provider type. METHODS A retrospective, observational study was conducted of 72 unannounced, monthly simulated pediatric medical emergencies ("mock codes") in a tertiary care, academic pediatric hospital. Responders were code team members, including pediatric residents and interns (MDs), respiratory therapists (RTs), and nurses (RNs). All sessions were video-recorded and reviewed for the rate of BVM ventilation, rate of chest compressions, and the team members performing these tasks. The type of emergency, location of the code, and training level of the team leader were also recorded. RESULTS Hyperventilation was present in every mock code reviewed. The mean rate of BVM ventilation for all providers in all scenarios was 40.6 ± 11.8 breaths per minute (BPM). The mean ventilation rates for RNs, RTs, and MDs were 40.8 ± 14.7, 39.9 ± 11.7, and 40.5 ± 10.3 BPM, respectively, and did not differ among providers (P = .94). All rates were significantly higher than the recommended rate of 8 to 20 BPM (per Pediatric Advanced Life Support guidelines, varies with patient age) (P < .001). The mean ventilation rate in cases of isolated respiratory arrest was 44.0 ± 13.9 BPM and was not different from the mean BVM ventilation rate in cases of cardiopulmonary arrest (38.9 ± 14.4 BPM; P = .689). CONCLUSIONS Hyperventilation occurred in simulated pediatric resuscitation and did not vary according to provider type. Future educational interventions should focus on avoidance of excessive ventilation.
Collapse
Affiliation(s)
- Julia M Niebauer
- Division of Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
| | | | | | | | | |
Collapse
|
54
|
Kirkham F. Cardiac arrest and post resuscitation of the brain. Eur J Paediatr Neurol 2011; 15:379-89. [PMID: 21640621 DOI: 10.1016/j.ejpn.2011.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 04/17/2011] [Indexed: 10/18/2022]
Abstract
Primary out-of-hospital cardiac arrest in childhood is rare but survival is a little better for children than for adults, although the prognosis for infants is very poor. Hypoxic-ischaemic encephalopathy after in-hospital cardiac arrest in children undergoing complicated treatment for previously untreatable conditions is now a common problem and is probably increasing. An additional ischaemic insult worsens the prognosis for other encephalopathies, such as that occurring after accidental or non-accidental head injury. For near-drowning, the prognosis is often good, provided that cardiopulmonary resuscitation (CPR) is commenced immediately, and the child gasps within 40 minutes of rescue and regains consciousness soon afterwards. The prognosis is much worse for the nearly drowned child admitted to casualty or the emergency room deeply unconscious with fixed dilated pupils, requiring continuing CPR and with an arterial pH <7, especially if there is little recovery by the time of admission to the intensive care unit. The use of adrenaline, sodium bicarbonate and calcium appears to worsen prognosis. Neurophysiology, specifically serial electroencephalography and evoked potentials, is the most useful tool prognostically, although neuroimaging and biomarkers may play a role. In a series of 89 patients studied after cardiac arrest in three London centres between 1982 and 1985, 39% recovered consciousness within one month. Twenty seven percent died a cardiac death whilst in coma, and the outcome in the remainder was either brain death or vegetative state. EEG and initial pH were the best predictors of outcome in this study. Seizures affected one third and were associated with deterioration and worse outcome. The advent of extracorporeal membrane oxygenation (ECMO) and the positive results of hypothermia trials in neonates and adults have rekindled interest in timely management of this important group of patients.
Collapse
|
55
|
|
56
|
Guilfoyle FJ, Milner R, Kissoon N. Resuscitation interventions in a tertiary level pediatric emergency department: implications for maintenance of skills. CAN J EMERG MED 2011; 13:90-5. [PMID: 21435314 DOI: 10.2310/8000.2011.110230] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe the frequency and proportion of successful resuscitation interventions in a pediatric emergency department (PED). METHODS AND MATERIAL This was a retrospective chart review of children at the BC Children's Hospital (BCCH) PED who were admitted to the BCCH pediatric intensive care unit (PICU) in 2004 and 2005. Demographic data, diagnosis, and resuscitation interventions in the PED and within the first 24 hours of PICU admission were recorded. The training of the operator and the number of attempts needed were also recorded. RESULTS There were 75,133 PED visits; 304 of 329 (92.4%) who met inclusion criteria were reviewed. Diagnoses included respiratory distress (n=115, 35%), trauma (n=50, 15%), sepsis (n=36, 11%), seizures (n=37, 11%), and cardiac disease (n=22, 7%). Ninety-nine patients required intubation. Intubations in the PED were performed by residents (20%), pediatric emergency medicine (PEM) fellows (15%), PEM attending staff (29%), and PICU fellows (12%); 81% of these were successful on the first attempt. In the PED, seven central lines were placed, seven intraosseous needles were inserted, 15 patients required inotropes, and 9 patients required chest compressions. CONCLUSION Critical illness in our emergency department is a rare event; hence, opportunities to resuscitate, secure airways, and place central venous catheters are limited. Additional training, close working relationships between the PED and the PICU teams, and resuscitation protocols for early PICU involvement may be needed.
Collapse
Affiliation(s)
- F Jonathan Guilfoyle
- Department of Paediatrics, Division of Emergency Medicine, Alberta Children’s Hospital, Calgary, AB
| | | | | |
Collapse
|
57
|
Sutton RM, Niles D, Meaney PA, Aplenc R, French B, Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarni V. Low-dose, high-frequency CPR training improves skill retention of in-hospital pediatric providers. Pediatrics 2011; 128:e145-51. [PMID: 21646262 PMCID: PMC3387915 DOI: 10.1542/peds.2010-2105] [Citation(s) in RCA: 174] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate the effectiveness of brief bedside cardiopulmonary resuscitation (CPR) training to improve the skill retention of hospital-based pediatric providers. We hypothesized that a low-dose, high-frequency training program (booster training) would improve CPR skill retention. PATIENTS AND METHODS CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated arrest. Basic life support-certified, hospital-based providers were randomly assigned to 1 of 4 study arms: (1) instructor-only training; (2) automated defibrillator feedback only; (3) instructor training combined with automated feedback; and (4) control (no structured training). Each session (time: 0, 1, 3, and 6 months after training) consisted of a pretraining evaluation (60 seconds), booster training (120 seconds), and a posttraining evaluation (60 seconds). Excellent CPR was defined as chest compression (CC) depth ≥ one-third anterior-posterior chest depth, rate ≥90 and ≤120 CC per minute, ≤20% of CCs with incomplete release (>2500 g), and no flow fraction ≤ 0.30. MEASUREMENTS AND MAIN RESULTS Eighty-nine providers were randomly assigned; 74 (83%) completed all sessions. Retention of CPR skills was 2.3 times (95% confidence interval [CI]: 1.1-4.5; P=.02) more likely after 2 trainings and 2.9 times (95% CI: 1.4-6.2; P=.005) more likely after 3 trainings. The automated defibrillator feedback only group had lower retention rates compared with the instructor-only training group (odds ratio: 0.41 [95% CI: 0.17-0.97]; P = .043). CONCLUSIONS Brief bedside booster CPR training improves CPR skill retention. Our data reveal that instructor-led training improves retention compared with automated feedback training alone. Future studies should investigate whether bedside training improves CPR quality during actual pediatric arrests.
Collapse
Affiliation(s)
| | - Dana Niles
- Center for Simulation, Advanced Education, and Innovation, and
| | | | - Richard Aplenc
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | | | - Benjamin S. Abella
- Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, ,Center for Simulation, Advanced Education, and Innovation, and
| |
Collapse
|
58
|
Briassoulis G, Briassoulis P, Briassouli E. Educational polymorphisms of basic life support algorithms. J Eval Clin Pract 2011; 17:462-70. [PMID: 20553365 DOI: 10.1111/j.1365-2753.2010.01450.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A systematic review of the pooled effect of articles presenting current basic life support (BLS) algorithms for the treatment of cardiac arrest has never been carried. AIMS We aimed to record and classify potential inherent factors influencing simplicity negatively in teaching, learning and retention of cardiopulmonary resuscitation (CPR) delivered by health care providers or lay persons. METHODS We performed a search of the relevant literature exploring MEDLINE, COCHRANE LIBRARY and SCOPUS databases. Potential inhibitory factors in the structure of available algorithms influencing simplicity in teaching, learning and retention of BLS were recorded and stratified accordingly. In a second phase of this study, we tested the hypothesis that different options of a BLS algorithm might influence CPR retention negatively, by asking 348 health care provider participants of our CPR seminars to describe their predicted response in an emergency to: (1) a real-time model implicating the various victims and rescuers; and (2) a hypothetical challenging 'all-in-one' BLS algorithm model. RESULTS Fifteen articles presenting current BLS algorithms evidenced 163 suggestions that produced 23 different CPR options: five contrasting algorithms (21.8%); three two-option models (13%); six vague technical or scientific suggestions (26%); and nine multiple choices of action (39.1%). Identified references contributed differently in the development of educationally polymorphic BLS options in each of the four categories (P < 0.0001) and were all brought about by variants of victims and rescuers. Participants of CPR seminars answered that in an emergency they could remember the hypothetical BLS model (90%, P = 0.007) rather than a current BLS algorithm for adults (42.2%) or children (36%). CONCLUSIONS Educational polymorphisms of BLS algorithms could build unpredictable barriers between rescuers and cardiac arrest victims and might seriously limit instructors' educational effectiveness. These findings might support an alternative trial hypothesis of a simple 'all-in-one algorithm' educational approach in future.
Collapse
Affiliation(s)
- George Briassoulis
- School of Health Sciences, University of Crete, Heraklion, Crete, Greece.
| | | | | |
Collapse
|
59
|
Wang GS, Erwin N, Zuk J, Henry DB, Dobyns EL. Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital. J Hosp Med 2011; 6:131-5. [PMID: 21387548 DOI: 10.1002/jhm.832] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 03/03/2010] [Accepted: 07/02/2010] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Pediatric in-hospital arrests are uncommon but are associated with poor outcomes. In preparation for implenting a Rapid Response Team (RRT) at The Children's Hospital, we reviewed our data collection of 13 years of emergency response team (ERT) activations. We describe demographic and clinical variables, including outcomes of ERT activations at a free-standing tertiary care children's hospital. METHODS Analysis was performed on data collected from January 1993 through July 2007. Variables collected included age, sex, admission diagnosis, core event, admission diagnosis and secondary diagnosis, medical division or winter/nonwinter months, day/night shifts, survival of core event, survival to discharge, and primary attending service. RESULTS There were 1537 ERT activations in the database, 203 were eliminated due to missing data or were adult visitors/employees. The remaining 1334 were included for analysis. Our results showed 39%(511) of all ERT activations occurred in patients under 1 year of age. The most common admission diagnosis category was cardiac disease. There was no statistical significance between summer and winter months although more activations occurred during daytime hours (P < .001). Survival rate of an ERT was 90%, with a 78% survival rate to discharge. CONCLUSION Our data support the general belief that younger children with chronic disease are at highest risk for ERT activations. These risk factors should be taken into consideration when planning patient placement, medical staffing, and the threshold for ICU consultations or admissions. More extensive multisite studies using clinical data are necessary to further identify hospitalized children at risk for sudden decompensation.
Collapse
Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine, The Children's Hospital, Aurora, Colorado, USA.
| | | | | | | | | |
Collapse
|
60
|
Meaney PA, Nadkarni VM, Atkins DL, Berg MD, Samson RA, Hazinski MF, Berg RA. Effect of defibrillation energy dose during in-hospital pediatric cardiac arrest. Pediatrics 2011; 127:e16-23. [PMID: 21172997 DOI: 10.1542/peds.2010-1617] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the effectiveness of initial defibrillation attempts. We hypothesized that (1) an initial shock dose of 2 ± 10 J/kg would be less effective for terminating fibrillation than suggested in published historical data and (2) a 4 J/kg shock dose would be more effective. PATIENTS AND METHODS This was a National Registry of Cardiopulmonary Resuscitation prospective, multisite, observational study of in-hospital pediatric (aged ≤18 years) ventricular fibrillation or pulseless ventricular tachycardia cardiac arrests from 2000-2008. Termination of ventricular fibrillation or pulseless ventricular tachycardia and event survival after initial shocks of 2 J/kg were compared with historic controls and a 4 J/kg shock dose. RESULTS Of 266 children with 285 events, 173 of 285 (61%) survived the event and 61 of 266 (23%) survived to discharge. Termination of fibrillation after initial shock was achieved for 152 of 285 (53%) events. Termination of fibrillation with 2 ± 10 J/kg was much less frequent than that seen among historic control subjects (56% vs 91%; P < .001), but not different than 4 J/kg. Compared with 2 J/kg, an initial shock dose of 4 J/kg was associated with lower rates of return of spontaneous circulation (odds ratio: 0.41 [95% confidence interval: 0.21-0.81]) and event survival (odds ratio: 0.42 [95% confidence interval: 0.18-0.98]). CONCLUSIONS The currently recommended 2 J/kg initial shock dose for in-hospital cardiac arrest was substantially less effective than previously published. A higher initial shock dose (4 J/kg) was not associated with superior termination of ventricular fibrillation or pulseless ventricular tachycardia or improved survival rates. The optimal pediatric defibrillation dose remains unknown.
Collapse
Affiliation(s)
- Peter A Meaney
- Department of Anesthesiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | |
Collapse
|
61
|
Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatr Crit Care Med 2011; 12:33-8. [PMID: 20581734 DOI: 10.1097/pcc.0b013e3181e89270] [Citation(s) in RCA: 253] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the viability and effectiveness of a simulation-based pediatric mock code program on patient outcomes, as well as residents' confidence in performing resuscitations. A resident's leadership ability is integral to accurate and efficient clinical response in the successful management of cardiopulmonary arrest (CPA). Direct experience is a contributing factor to a resident's code team leadership ability; however, opportunities to gain experience are limited by relative infrequency of pediatric arrests and code occurrences when residents are on service. DESIGN Longitudinal, mixed-methods research design. SETTING Children's hospital at an tertiary care academic medical center. PATIENTS Pediatric. INTERVENTIONS Clinicians responsible for pediatric resuscitations responded to mock codes randomly called at increasing rates over a 48-month period, just as they would an actual CPA event. Events were recorded and used for immediate debriefing facilitated by clinical faculty to provide residents feedback about their performance. MEASUREMENTS Self-assessment data were collected from all team members. Hospital records for pediatric CPA survival rates were examined for the study duration. RESULTS Survival rates increased to approximately 50% (p = .000), correlating with the increased number of mock codes (r = .87). These results are significantly above the average national pediatric CPA survival rates and held steady for 3 consecutive years, demonstrating the stability of the program's outcomes. CONCLUSIONS This study suggests that a simulation-based mock code program may significantly benefit pediatric patient CPA outcomes-applied clinical outcomes-not simply learner perceived value, increased confidence, or simulation-based outcomes. The use of mock codes as an integral part of residency programs could provide residents with the resuscitation training they require to become proficient in their practice. Future programs that incorporate transport scenarios, ambulatory care, and other outpatient settings could further benefit pediatric patients in prehospital contexts.
Collapse
|
62
|
Fonarow GC, Gregory T, Driskill M, Stewart MD, Beam C, Butler J, Jacobs AK, Meltzer NM, Peterson ED, Schwamm LH, Spertus JA, Yancy CW, Tomaselli GF, Sacco RL. Hospital certification for optimizing cardiovascular disease and stroke quality of care and outcomes. Circulation 2010; 122:2459-69. [PMID: 21098429 DOI: 10.1161/cir.0b013e3182011a81] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular disease and stroke remain leading causes of mortality, disability, and rising healthcare expenditures in the United States. Although a number of organizations provide hospital accreditation, recognition, and certification programs, existing programs do not address cardiovascular disease and stroke care in a comprehensive way. Current evidence suggests mixed findings for correlation between accreditation, recognition, and certification programs and hospitals' actual quality of care and outcomes. This advisory discusses potential opportunities to develop and enhance hospital certification programs for cardiovascular disease and stroke. The American Heart Association/American Stroke Association is uniquely positioned as a patient-centered, respected, transparent healthcare organization to help drive improvements in care and outcomes for patients hospitalized with cardiovascular disease and stroke. As a part of its commitment to promoting high-quality, evidence-based care for cardiovascular and stroke patients, it is recommended that the American Heart Association/American Stroke Association explore hospital certification programs to develop truly meaningful programs to facilitate improvements in and recognition for cardiovascular disease and stroke quality of care and outcomes. Future strategies should standardize objective, unbiased assessments of hospital structural, process, and outcome performance while allowing flexibility as technology and methodology advances occur.
Collapse
|
63
|
Garden AL, Mills SA, Wilson R, Watts P, Griffin JM, Gannon S, Kapoor I. In Situ Simulation Training for Paediatric Cardiorespiratory Arrest: Initial Observations and Identification of Latent Errors. Anaesth Intensive Care 2010; 38:1038-42. [DOI: 10.1177/0310057x1003800613] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In response to a successful, although difficult resuscitation in one of our paediatric wards, we developed and implemented an educational program to improve the resuscitation skills, teamwork and safety climate in our multidisciplinary acute-care paediatric service. The program is ongoing and consists of didactic presentations, high-fidelity in situ simulation and facilitated debriefing to encourage reflective learning. The underlying goal, to provide this training to all staff over a two-year period, should be achieved by late 2011. In this preliminary report we describe teamwork difficulties that are commonly found during such training. These included inconsistent leadership behaviours, inadequate delegation of areas of responsibility, failure to communicate problems during the execution of technical tasks (such as difficulty opening the resuscitation trolley) and failure to challenge inadequate or inappropriate therapy (such as poor chest expansion during bag-mask ventilation). In addition, we unexpectedly discovered seven latent errors in our clinical environment during the first nine months of course delivery. The most disturbing of these was that participants repeatedly struggled to identify and overcome the locking-mechanism and tamper-proof device on a newly introduced resuscitation trolley.
Collapse
Affiliation(s)
- A. L. Garden
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Associate Professor and Clinical Associate Director
| | - S. A. Mills
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Paediatric Fellow, Department of Child Health, Wellington Regional Hospital
| | - R. Wilson
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Specialist Paediatrician and Clinical Leader, Department of Child Health, Wellington Regional Hospital
| | - P. Watts
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Technology Specialist, National Patient Simulation Training Centre, Wellington Regional Hospital
| | - J. M. Griffin
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Clinical Nurse Specialist, Department of Child Health, Wellington Regional Hospital
| | - S. Gannon
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Clinical Nurse Educator, Department of Child Health, Wellington Regional Hospital
| | - I. Kapoor
- Sleep Wake Research Centre, Massey University, Wellington, New Zealand
- Specialist Anaesthetist, Department of Anaesthesia, Wellington Hospital
| |
Collapse
|
64
|
O'Leary FM, Janson P. Can e-learning improve medical students' knowledge and competence in paediatric cardiopulmonary resuscitation? A prospective before and after study. Emerg Med Australas 2010; 22:324-9. [DOI: 10.1111/j.1742-6723.2010.01302.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
65
|
Abstract
OBJECTIVES Resuscitation of the acutely ill child is a necessary skill for pediatric residents. The effects of a hospital-wide mock code program on involvement, anxiety, and leadership have not been studied. We hypothesized that after 1 year of mock codes, pediatric residents would report (1) increased participation, (2) decreased anxiety and increased comfort with knowledge, and (3) increased likelihood of leading and feeling capable of running a code. METHODS In this cross-sectional study of pediatric residents, anonymous surveys evaluated involvement, comfort, and leadership in codes before and 1 year after a monthly mock code curriculum was incorporated into the resident educational curriculum. The survey measured residents' involvement in actual and mock codes and levels of anxiety, knowledge, and leadership ability during codes. RESULTS Approximately 60 residents returned completed survey forms each year. Attendance and participation at actual codes were not significantly changed between years. For mock codes, there was a significant change (P < 0.001) in both observation and participation. After 1 year, residents reported a statistically significant increase in their comfort with knowledge during a code (odds ratio, 2.5; 95% confidence interval, 1.2-5.2). They also reported a decrease in anxiety and felt more capable of running a code, although these numbers were not statistically significant. CONCLUSIONS One year after starting a mock code program, residents attended more mock codes and reported more comfort with knowledge in codes. A continued monthly mock code program will provide residents with critical skills training and experience and may translate into active participation, increased leadership, and decreased anxiety in actual codes.
Collapse
|
66
|
Outcomes among neonates, infants, and children after extracorporeal cardiopulmonary resuscitation for refractory inhospital pediatric cardiac arrest: a report from the National Registry of Cardiopulmonary Resuscitation. Pediatr Crit Care Med 2010; 11:362-71. [PMID: 19924027 DOI: 10.1097/pcc.0b013e3181c0141b] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Describe the use of extracorporeal cardiopulmonary resuscitation as rescue therapy in pediatric patients who experience cardiopulmonary arrest refractory to conventional resuscitation. We report on outcomes and factors associated with survival in children treated with extracorporeal cardiopulmonary resuscitation during cardiopulmonary arrest from the American Heart Association National Registry of CardioPulmonary Resuscitation. DESIGN Multicentered, national registry of in-hospital cardiopulmonary resuscitation. SETTING Two hundred eighty-five hospitals reporting to the registry from January 2000 to December 2007. PATIENTS Pediatric patients <18 yrs of age who received extracorporeal membrane oxygenation during cardiopulmonary resuscitation for in-hospital cardiopulmonary arrest. INTERVENTIONS None. MEASUREMENTS AND OUTCOMES Prearrest and arrest variables were collected. The primary outcome variable was survival to hospital discharge. The secondary outcome was neurologic status after extracorporeal cardiopulmonary resuscitation at hospital discharge. Favorable neurologic outcome was defined as Pediatric Cerebral Performance Categories 1, 2, 3, or no change from admission Pediatric Cerebral Performance Category. RESULTS Of 6288 pediatric cardiopulmonary arrest events reported, 199 (3.2%) index extracorporeal cardiopulmonary resuscitation events were identified; 87 (43.7%) survived to hospital discharge. Fifty-nine survivors had Pediatric Cerebral Performance Category outcomes recorded, and of those, 56 (94.9%) had favorable outcomes. In a multivariable model, the prearrest factor of renal insufficiency and arrest factors of metabolic or electrolyte abnormality and the pharmacologic intervention of sodium bicarbonate/tromethamine were associated with decreased survival. After adjusting for confounding factors, cardiac illness category was associated with an increased survival to hospital discharge. CONCLUSIONS Forty-four percent of pediatric patients who failed conventional cardiopulmonary resuscitation from in-hospital cardiopulmonary arrest and who were reported to the National Registry of CardioPulmonary Resuscitation database as treated with extracorporeal cardiopulmonary resuscitation survived to hospital discharge. The majority of survivors with recorded neurologic outcomes were favorable. Patients with cardiac illness category were more likely to survive to hospital discharge after treatment with extracorporeal cardiopulmonary resuscitation. Extracorporeal cardiopulmonary resuscitation should be considered for select pediatric patients refractory to conventional in-hospital resuscitation measures.
Collapse
|
67
|
Abstract
Amiodarone is a class 3 antiarrhythmic agent used for a broad range of arrhythmias including adenosine-resistant supraventricular tachycardia, junctional ectopic tachycardia, and ventricular tachycardia. Compared with adults, there are few data on its use in children with arrhythmias resistant to conventional therapy. National and international guidelines for cardiopulmonary resuscitation and emergency cardiovascular care recommend its use for a variety of arrhythmias based on case reports, cohort studies, and extrapolation from adult data. This article will review the historical development, chemical properties, metabolism, indications and contraindications, and adverse effects of amiodarone in infants and children. After completing this CME activity, the reader should be able to utilize amiodarone in the pediatric population for arrhythmias and identify complications associated with its use.
Collapse
|
68
|
Srinivasan V, Nadkarni VM, Helfaer MA, Carey SM, Berg RA. Childhood obesity and survival after in-hospital pediatric cardiopulmonary resuscitation. Pediatrics 2010; 125:e481-8. [PMID: 20176666 DOI: 10.1542/peds.2009-1324] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We hypothesized that childhood obesity would be associated with decreased likelihood of survival to hospital discharge after in-hospital, pediatric cardiopulmonary resuscitation (CPR). METHODS We reviewed 1477 consecutive, pediatric, CPR index events (defined as the first CPR event during a hospitalization in that facility for a patient <18 years of age) reported to the American Heart Association National Registry of Cardiopulmonary Resuscitation between January 2000 and July 2004. The primary outcome was survival to hospital discharge. A total of 1268 index subjects (86%) with complete registry data were included for analysis. Children were classified as obese (> or =95th weight-for-length percentile if <2 years of age or > or =95th BMI-for-age percentile if > or =2 years of age) or underweight (<5th weight-for-length percentile if <2 years of age or <5th BMI-for-age percentile if > or =2 years of age), with adjustment for gender. RESULTS Obesity was noted for 213 (17%) of 1268 subjects and underweight for 571 (45%) of 1268 subjects. Obesity was more likely to be associated with male gender, noncardiac medical illness, and cancer and inversely associated with heart failure. Underweight was more likely to be associated with male gender, cardiac surgery, and prematurity and inversely associated with age and cancer. Self-reported, process-of-care, CPR quality was generally worse for obese children. With adjustment for important potential confounding factors, obesity was independently associated with worse odds of event survival (adjusted odds ratio: 0.58 [95% confidence interval: 0.35-0.76]) and survival to hospital discharge (adjusted odds ratio: 0.62 [95% confidence interval: 0.38-0.93]) after in-hospital, pediatric CPR. Underweight was not associated with worse outcomes. CONCLUSIONS Childhood obesity is associated with a lower rate of survival to hospital discharge after in-hospital, pediatric CPR.
Collapse
Affiliation(s)
- Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | | | | | | | | | | |
Collapse
|
69
|
Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bbttiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth W, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part II). Int Emerg Nurs 2010; 18:8-28. [DOI: 10.1016/j.ienj.2009.07.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
70
|
Donoghue A, Berg RA, Hazinski MF, Praestgaard AH, Roberts K, Nadkarni VM. Cardiopulmonary resuscitation for bradycardia with poor perfusion versus pulseless cardiac arrest. Pediatrics 2009; 124:1541-8. [PMID: 19917587 DOI: 10.1542/peds.2009-0727] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to assess whether pediatric inpatients who receive cardiopulmonary resuscitation (CPR) for bradycardia with poor perfusion are more likely to survive to hospital discharge than pediatric inpatients who receive CPR for pulseless arrest (asystole/pulseless electrical activity [PEA]), after controlling for confounding characteristics. METHODS A prospective cohort from the National Registry of Cardiopulmonary Resuscitation was enrolled between January 4, 2000, and February 23, 2008. Patients who were younger than 18 years and had an in-hospital event that required chest compressions for >2 minutes were eligible. Patients were divided into 2 groups on the basis of initial rhythm and pulse state: bradycardia/poor perfusion and asystole/PEA. Patient characteristics, event characteristics, and clinical characteristics were analyzed as possible confounders. Univariate analysis between bradycardia and asystole/PEA patient groups was performed. Multivariable logistic regression was used to determine whether an initial state of bradycardia/poor perfusion was independently associated with survival to discharge. RESULTS A total of 6288 patients who were younger than 18 years were reported; 3342 met all inclusion criteria. A total of 1853 (55%) patients received chest compressions for bradycardia/poor perfusion compared with 1489 (45%) for asystole/PEA. Overall, 755 (40.7%) of 1353 patients with bradycardia survived to hospital discharge, compared with 365 (24.5%) of 1489 patients with asystole/PEA. After controlling for known confounders, CPR for bradycardia with poor perfusion was associated with increased survival to hospital discharge. CONCLUSIONS Pediatric inpatients with chest compressions initiated for bradycardia and poor perfusion before onset of pulselessness were more likely to survive to discharge than pediatric inpatients with chest compressions initiated for asystole or PEA.
Collapse
Affiliation(s)
- Aaron Donoghue
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
| | | | | | | | | | | | | |
Collapse
|
71
|
Pediatric in-hospital cardiac arrest and therapeutic hypothermia: where we are and where we are going. Pediatr Crit Care Med 2009; 10:601-2. [PMID: 19741448 DOI: 10.1097/pcc.0b013e3181ae490c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
72
|
Meert KL, Donaldson A, Nadkarni V, Tieves KS, Schleien CL, Brilli RJ, Clark RSB, Shaffner DH, Levy F, Statler K, Dalton H, van der Jagt EW, Hackbarth R, Pretzlaff R, Hernan L, Dean JM, Moler FW. Multicenter cohort study of in-hospital pediatric cardiac arrest. Pediatr Crit Care Med 2009; 10:544-53. [PMID: 19451846 PMCID: PMC2741542 DOI: 10.1097/pcc.0b013e3181a7045c] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES 1) To describe clinical characteristics, hospital courses, and outcomes of a cohort of children cared for within the Pediatric Emergency Care Applied Research Network who experienced in-hospital cardiac arrest with sustained return of circulation between July 1, 2003 and December 31, 2004, and 2) to identify factors associated with hospital mortality in this population. These data are required to prepare a randomized trial of therapeutic hypothermia on neurobehavioral outcomes in children after in-hospital cardiac arrest. DESIGN Retrospective cohort study. SETTING Fifteen children's hospitals associated with Pediatric Emergency Care Applied Research Network. PATIENTS Patients between 1 day and 18 years of age who had cardiopulmonary resuscitation and received chest compressions for >1 min, and had a return of circulation for >20 mins. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 353 patients met entry criteria; 172 (48.7%) survived to hospital discharge. Among survivors, 132 (76.7%) had good neurologic outcome documented by Pediatric Cerebral Performance Category scores. After adjustment for age, gender, and first documented cardiac arrest rhythm, variables available before and during the arrest that were independently associated with increased mortality included pre-existing hematologic, oncologic, or immunologic disorders, genetic or metabolic disorders, presence of an endotracheal tube before the arrest, and use of sodium bicarbonate during the arrest. Variables associated with decreased mortality included postoperative cardiopulmonary resuscitation. Extending the time frame to include variables available before, during, and within 12 hours following arrest, variables independently associated with increased mortality included the use of calcium during the arrest. Variables associated with decreased mortality included higher minimum blood pH and pupillary responsiveness. CONCLUSIONS Many factors are associated with hospital mortality among children after in-hospital cardiac arrest and return of circulation. Such factors must be considered when designing a trial of therapeutic hypothermia after cardiac arrest in pediatric patients.
Collapse
|
73
|
Abstract
PURPOSE OF REVIEW To summarize recent advances in pediatric cardiopulmonary arrest prevention, resuscitation and postresuscitation management. RECENT FINDINGS Pediatric cardiac arrest has traditionally been considered a futile medical condition with dismal outcomes. Data in the 21st century indicate that more than 25% of children treated for in-hospital cardiac arrests survive to hospital discharge and more than 10% of children older than 1 year treated for out-of-hospital cardiac arrests survive to hospital discharge. These data establish that children are more likely to survive to hospital discharge than adults after both in-hospital and out-of-hospital cardiac arrests. Before arrest, exciting new studies demonstrate that the implementation of in-hospital pediatric medical emergency teams is associated with significant decreases in cardiac arrest incidence and overall pediatric hospital mortality. During arrest, ventricular fibrillation or ventricular tachycardia, once thought to be rare in children, occurs during 25% of inhospital pediatric cardiac arrests and at least 7% of out-of-hospital pediatric cardiac arrests. Survival to hospital discharge is much more likely after arrests with a first documented rhythm of ventricular fibrillation or ventricular tachycardia than after pulseless electric activity and asystole. However, ventricular fibrillation or ventricular tachycardia is not always a favorable rhythm, as survival to discharge is much less likely when ventricular fibrillation or ventricular tachycardia occurs during resuscitation from an arrest with the first documented rhythm of pulseless electric activity or asystole. Further, extracorporeal membrane oxygenation cardiopulmonary resuscitation appears promising under special resuscitation circumstances to improve outcome from highly selected in-hospital pediatric cardiac arrest victims. Further, postresuscitation interventions such as goal-directed therapies and therapeutic hypothermia have been demonstrated in adults and infants to improve outcome for selected cardiac arrest victims and are promising candidate targets for study in children. SUMMARY Pediatric cardiac arrest is not a futile condition; many children are successfully resuscitated each year. The implementation of new prearrest, intraarrest and postresuscitative therapies has the potential to further improve survival rates following pediatric cardiac arrest.
Collapse
|
74
|
|
75
|
Sutton RM, Niles D, Nysaether J, Arbogast KB, Nishisaki A, Maltese MR, Bishnoi R, Helfaer MA, Nadkarni V, Donoghue A. Pediatric CPR quality monitoring: analysis of thoracic anthropometric data. Resuscitation 2009; 80:1137-41. [PMID: 19647359 DOI: 10.1016/j.resuscitation.2009.06.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Revised: 05/20/2009] [Accepted: 06/30/2009] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Quantitative CPR quality feedback systems improve adult CPR performance. Extension to pediatric patients is desirable; however, the anthropometric measurements of the pediatric chest pertinent to guide the development of pediatric-specific CPR monitoring systems are largely unknown. HYPOTHESIS Adult-based CPR quality monitoring and feedback systems will require pediatric-specific tailoring and adaptation. METHODS Anthropometric measurements pertinent to the development of pediatric-specific CPR quality monitoring systems were obtained in 150 children ages 6 months to 8 years. Standard descriptive statistics were calculated. Absolute depth point estimates and 95% confidence intervals were calculated for the American Heart Association (AHA) chest compression depth recommendations (1/3 and 1/2 Anterior-Posterior chest depth). Percentage of subjects for which the adult minimal feedback depth of 38mm would coach to achieve pediatric AHA target depths was determined. RESULTS Point estimate averages for measurements pertinent to pediatric adaptation of CPR monitoring technology were: sternal width: 25.1mm [22.0-29.2]; sternal length: 98.7mm [95.3-102.1]; internipple distance: 120.0mm [117.2-122.8]; chin to sternal notch: 35.3mm [31.2-39.4]; 1/3 AP chest depth: 37.0mm [36.1-37.8]; and 1/2 AP chest depth: 55.4mm [54.2-56.7]. A minimal feedback depth of 38mm would meet the minimum pediatric AHA target for depth in 55% (82/148) of subjects, and coach too deep in only 2% (3/148). CONCLUSION Extension of adult-based CPR quality monitoring and feedback systems will require pediatric-specific tailoring and adaptation. Future studies should examine chest compression depths in clinical settings with correlation to physiologic parameters to determine the best targets for pediatric CPR guidelines.
Collapse
Affiliation(s)
- Robert M Sutton
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
76
|
Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bbttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part 1). Int Emerg Nurs 2009; 17:203-25. [PMID: 19782333 DOI: 10.1016/j.ienj.2009.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIM OF THE REVIEW To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. METHODS Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. RESULTS The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. CONCLUSIONS A growing body of knowledge suggests that the individual components of the postcardiac arrest syndrome are potentially treatable.
Collapse
Affiliation(s)
- Jerry P Nolan
- Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
77
|
Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation. Pediatr Crit Care Med 2009; 10:445-51. [PMID: 19451851 DOI: 10.1097/pcc.0b013e318198bd85] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) to aid failed cardiopulmonary resuscitation (CPR) in children is associated with a high incidence of neurologic injury. We sought to identify risk factors for acute neurologic injury in children undergoing ECMO to aid CPR (E-CPR). DESIGN Retrospective cohort study using data reported to the Extracorporeal Life Support Organization registry. SETTING Multi-institutional data. PATIENTS Patients <18 years of age undergoing E-CPR during 1992-2005. INTERVENTIONS None. MEASUREMENTS AND RESULTS We defined acute neurologic injury as the occurrence of brain death, brain infarction, or intracranial hemorrhage identified by ultrasound or computerized tomography imaging. Of 682 E-CPR patients, 147 (22%) patients had acute neurologic injury. Brain death occurred in 74 (11%), cerebral infarction in 45 (7%), and intracranial hemorrhage in 45 (7%). The in-hospital mortality rate in patients with acute neurologic injury was 89%. In a multivariable logistic regression model, pre-ECMO factors including cardiac disease (odds ratio [OR] 0.46 [95% confidence interval {CI} 0.28-0.76]) and pre-ECMO blood pH > or =6.865 (> or =6.865-7.120; OR 0.49 [95% CI 0.25-0.94]; pH >7.120; OR 0.47 [95% CI 0.26-0.85]) compared with pH <6.865 were associated with decreased odds of neurologic injury. During ECMO, neurologic injury was associated with ECMO complications including pulmonary hemorrhage (OR 1.93, 95% CI 1.1-3.4), dialysis use (OR 2.36, 95% CI 1.4-4.0), and CPR during ECMO support (OR 2.08, 95% CI 1.6-3.8). CONCLUSIONS Neurologic injury is a frequent complication in children undergoing E-CPR. Children with cardiac disease, less severe metabolic acidosis before ECMO, and an uncomplicated ECMO course have decreased odds of sustaining neurologic injury. Providing effective CPR and inclusion of brain protective therapies on ECMO should be considered in the future to improve neurologic outcomes for patients undergoing E-CPR.
Collapse
|
78
|
Effect of high-fidelity simulation on Pediatric Advanced Life Support training in pediatric house staff: a randomized trial. Pediatr Emerg Care 2009; 25:139-44. [PMID: 19262421 DOI: 10.1097/pec.0b013e31819a7f90] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the effect of high-fidelity simulation (SIM) on cognitive performance after a training session involving several mock resuscitations designed to teach and reinforce Pediatric Advanced Life Support (PALS) algorithms. METHODS Pediatric residents were randomized to high-fidelity simulation (SIM) or standard mannequin (MAN) groups. Each subject completed 3 study phases: (1) mock code exercises (asystole, tachydysrhythmia, respiratory arrest, and shock) to assess baseline performance (PRE phase), (2) a didactic session reviewing PALS algorithms, and (3) repeated mock code exercises requiring identical cognitive skills in a different clinical context to assess change in performance (POST phase). SIM subjects completed all 3 phases using a high-fidelity simulator (SimBaby, Laerdal Medical, Stavanger, Norway), and MAN subjects used SimBaby without simulated physical findings (ie, as a standard mannequin). Performance in PRE and POST was measured by a scoring instrument designed to measure cognitive performance; scores were scaled to a range of 0 to 100 points. Improvement in performance from PRE to POST phases was evaluated by mixed modeling using a random intercept to account for within subject variability. RESULTS Fifty-one subjects (SIM, 25; MAN, 26) completed all phases. The PRE performance was similar between groups. Both groups demonstrated improvement in POST performance. The improvement in scores between PRE and POST phases was significantly better in the SIM group (mean [SD], 11.1 [4.8] vs. 4.8 [1.7], P = 0.007). CONCLUSIONS The use of high-fidelity simulation in a PALS training session resulted in improved cognitive performance by pediatric house staff. Future studies should address skill and knowledge decays and team dynamics, and clearly defined and reproducible outcome measures should be sought.
Collapse
|
79
|
Topjian A, Berg RA, Nadkarni VM. Pediatric Cardiopulmonary Arrest and Resuscitation. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-77383-4_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
80
|
Wu ET, Li MJ, Huang SC, Wang CC, Liu YP, Lu FL, Ko WJ, Wang MJ, Wang JK, Wu MH. Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan. Resuscitation 2009; 80:443-8. [PMID: 19223113 DOI: 10.1016/j.resuscitation.2009.01.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 01/08/2009] [Accepted: 01/12/2009] [Indexed: 10/21/2022]
Abstract
PURPOSE OF THE STUDY While the outcomes of cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) are reported for many regions, none is reported for Asian countries. We report the outcomes of CPR for pediatric IHCA in a tertiary medical center in Taiwan and also identify prognostic factors associated with poor outcome. METHODS Data were retrieved retrospectively from 2000 to 2003 and prospectively from 2004 to 2006 from our web-based registry system. We evaluated patients younger than 18 years of age who had IHCA and received CPR. The primary outcome was survival to hospital discharge, and the secondary outcomes were sustained return of spontaneous circulation (ROSC), and favorable neurological outcomes as assessed by pediatric cerebral performance categories (PCPC). RESULTS We identified 316 patients and the overall hospital survival was 20.9% and 16.1% had favorable neurological outcomes. Sixty-four patients ever supported with ECMO. We further analyzed 252 patients who underwent conventional CPR only and most had cardiac disease (133/252, 52.8%). The second most common preexisting condition was hematologic or oncologic disease (43/252, 17.1%). Of the 252 patients, 153 (60.7%) achieved sustained ROSC, 50 (19.8%) survived to discharge, and 39 patients (15.5%) had favorable neurological outcomes. CPR during off-work hours resulted in inferior chances of reaching sustained ROSC. Multivariate analysis showed that long CPR duration, hematology/oncology patients, and pre-arrest vasoactive drug infusion were significantly associated with decreased hospital survival (p<0.05). CONCLUSIONS Outcomes of CPR for pediatric patients with IHCA in Taiwan were comparable to corresponding reports in Western countries, but more hematology/oncology patients were included. Long CPR duration, hematologic or oncologic underlying diseases, and vasoactive agent infusion prior IHCA were associated with poor outcomes. The concept of palliative care should be proposed to families of terminally ill cancer patients in order to avoid unnecessary patient suffering. Also, establishing a balanced duty system in the future might increase chances of sustained ROSC.
Collapse
Affiliation(s)
- En-Ting Wu
- Department of Pediatrics, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
81
|
Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Vanden Hoek T. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation 2008; 118:2452-83. [PMID: 18948368 DOI: 10.1161/circulationaha.108.190652] [Citation(s) in RCA: 1064] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
82
|
Topjian AA, Berg RA, Nadkarni VM. Pediatric cardiopulmonary resuscitation: advances in science, techniques, and outcomes. Pediatrics 2008; 122:1086-98. [PMID: 18977991 PMCID: PMC2680157 DOI: 10.1542/peds.2007-3313] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
More than 25% of children survive to hospital discharge after in-hospital cardiac arrests, and 5% to 10% survive after out-of-hospital cardiac arrests. This review of pediatric cardiopulmonary resuscitation addresses the epidemiology of pediatric cardiac arrests, mechanisms of coronary blood flow during cardiopulmonary resuscitation, the 4 phases of cardiac arrest resuscitation, appropriate interventions during each phase, special resuscitation circumstances, extracorporeal membrane oxygenation cardiopulmonary resuscitation, and quality of cardiopulmonary resuscitation. The key elements of pathophysiology that impact and match the timing, intensity, duration, and variability of the hypoxic-ischemic insult to evidence-based interventions are reviewed. Exciting discoveries in basic and applied-science laboratories are now relevant for specific subpopulations of pediatric cardiac arrest victims and circumstances (eg, ventricular fibrillation, neonates, congenital heart disease, extracorporeal cardiopulmonary resuscitation). Improving the quality of interventions is increasingly recognized as a key factor for improving outcomes. Evolving training strategies include simulation training, just-in-time and just-in-place training, and crisis-team training. The difficult issue of when to discontinue resuscitative efforts is addressed. Outcomes from pediatric cardiac arrests are improving. Advances in resuscitation science and state-of-the-art implementation techniques provide the opportunity for further improvement in outcomes among children after cardiac arrest.
Collapse
Affiliation(s)
- Alexis A. Topjian
- Department of Anesthesia and Critical Care Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert A. Berg
- Department of Anesthesia and Critical Care Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, Department of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona
| | - Vinay M. Nadkarni
- Department of Anesthesia and Critical Care Medicine, University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
83
|
Adams JA, Bassuk JA, Arias J, Wu H, Jorapur V, Lamas GA, Kurlansky P. Acute effects of "delayed postconditioning" with periodic acceleration after asphyxia induced shock in pigs. Pediatr Res 2008; 64:533-7. [PMID: 18596578 DOI: 10.1203/pdr.0b013e318183f147] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Asphyxia cardiac arrest and shock are models for whole body ischemia reperfusion injury. Periodic acceleration (pGz) achieved by moving the body on a platform is a novel method for inducing pulsatile vascular shear stress and endogenous production of endothelial nitric oxide, prostaglandin E2, tissue plasminogen activator, and adrenomedullin. The aforementioned are cardioprotective during and after ischemia reperfusion injury. We investigated whether pGz, applied 15 min after return of spontaneous circulation (ROSC) would serve as an effective "delayed" post conditioning tactic to lessen acute reperfusion injury markers in a pediatric swine model of asphyxia induced shock. Asphyxia shock was induced in 20 swine weight 3.9 +/- 0.6 kg. Fifteen minutes after ROSC, the animals were randomized to receive conventional mechanical ventilation (CMV, [Control]) or CMV with pGz. All animals had ROSC and no significant differences in blood gases or hemodynamics after ROSC. pGz treated had significantly less myocardial dysfunction post resuscitation, (i.e. better % ejection fraction (EF), % fractional shortening (FS), and wall motion score index) and lower biochemical indices of reperfusion injury (lower TNF-alpha, IL-6, and Troponin I, and myeloperoxidase activity). Delayed postconditioning with pGz ameliorates acute post resuscitation reperfusion injury and improves myocardial dysfunction after asphyxia-induced shock.
Collapse
Affiliation(s)
- Jose A Adams
- Divisions of Neonatology, Mt Sinai Medical Center, Miami Beach, Florida 33140, USA.
| | | | | | | | | | | | | |
Collapse
|
84
|
Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 2008; 79:350-79. [PMID: 18963350 DOI: 10.1016/j.resuscitation.2008.09.017] [Citation(s) in RCA: 697] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 09/22/2008] [Indexed: 12/12/2022]
Abstract
AIM OF THE REVIEW To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. METHODS Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. RESULTS The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. CONCLUSIONS A growing body of knowledge suggests that the individual components of the post-cardiac arrest syndrome are potentially treatable.
Collapse
Affiliation(s)
- Jerry P Nolan
- Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
85
|
Jones DW, Peterson ED, Bonow RO, Masoudi FA, Fonarow GC, Smith SC, Solis P, Girgus M, Hinton PC, Leonard A, Gibbons RJ. Translating Research Into Practice for Healthcare Providers. Circulation 2008; 118:687-96. [DOI: 10.1161/circulationaha.108.189934] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The American Heart Association’s (AHA’s) mission is “to build healthier lives, free of cardiovascular diseases and stroke.” This first article in a 2-part series will serve to present an overview of the work the AHA has undertaken to translate evidence into practice for healthcare professionals. It describes the extensive work of the AHA to support and further the delivery of evidence-based medicine, which includes the following: (1) supporting scientific discovery and the next generation of healthcare professionals and researchers; (2) disseminating scientific information; (3) developing evidence-based guidelines and statements; (4) creating and advocating for the implementation of performance indicators/measures; (5) developing clinical decision support and quality improvement tools; and (6) developing directed-cause campaigns, all of which can lead to improved patient care. This article also discusses the need for novel approaches and some of the AHA’s evolving strategies to help address gaps in care. The second article, which will be published shortly after this one, will examine the AHA’s efforts to engage and empower healthcare consumers to become more involved with their own health and health care.
Collapse
Affiliation(s)
- Daniel W. Jones
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Eric D. Peterson
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Robert O. Bonow
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Frederick A. Masoudi
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Gregg C. Fonarow
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Sidney C. Smith
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Penelope Solis
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Meighan Girgus
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Patricia C. Hinton
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Anne Leonard
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| | - Raymond J. Gibbons
- From the University of Mississippi Medical Center, Jackson (D.W.J.); Duke University, Durham, NC (E.D.P.); Northwestern University Medical Center, Evanston, Ill (R.O.B.); Denver Health Medical Center, Denver, Colo (F.A.M.); University of California at Los Angeles Medical Center (G.C.F.); University of North Carolina at Chapel Hill (S.C.S.); American Heart Association, Dallas, Tex (P.S., M.G., P.C.H., A.L.); and Mayo Clinic, Rochester, Minn (R.J.G.)
| |
Collapse
|
86
|
Abstract
PURPOSE OF REVIEW To summarize current opinion and advances in pediatric cardiopulmonary resuscitation, including etiology, pathophysiology, rationale for interventions, and postresuscitation management. RECENT FINDINGS Cardiac arrest and ventricular fibrillation in children are not as uncommon as previously reported. Out-of-hospital cardiac arrests occur in 8-20 children/100,000/year, and in-hospital arrests occur in 2-6% admitted to a pediatric intensive care unit. Most pediatric arrests are precipitated by asphyxia or circulatory shock, but approximately 10% are precipitated by ventricular tachycardia or fibrillation. In addition, greater than 1/4 of children with in-hospital cardiac arrests have ventricular tachycardia or fibrillation at some time during the event. After out-of-hospital arrests, approximately 10% survive to hospital discharge, whereas greater than 25% survive to discharge after in-hospital arrests. Appropriate interventions differ during the four phases of cardiac arrest: prearrest, no-flow, low-flow, and postresuscitation. Close monitoring and prompt cardiopulmonary resuscitation can minimize the no-flow phase, good quality cardiopulmonary resuscitation is important during the low-flow phase, defibrillation is necessary for ventricular fibrillation, and aggressive supportive care is important during the postresuscitation phase. SUMMARY Recent advances in our understanding of the etiology, pathophysiology, and therapies tied to the timing, phase, and duration of cardiac arrest can improve outcomes for children. New epidemiological data and multicenter studies are ushering in the era of evidence-based pediatric resuscitation therapeutics.
Collapse
|
87
|
Abstract
The understanding of the incidence, epidemiology, etiology, and pathophysiology of pediatric cardiac arrest has evolved greatly in the past two decades. This includes recognition that cardiopulmonary resuscitation delays in cardiac arrest are especially injurious, ventricular arrhythmias are not as uncommon in children as previously believed, and four distinct phases of cardiac arrest can be delineated. Performance of, and technologic advances in, the treatment of cardiac arrest make this an exciting time in the field.
Collapse
Affiliation(s)
- Marc D Berg
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Steele Memorial Research Center and Sarver Heart Center, The University of Arizona College of Medicine, Tucson, AZ 85724, USA.
| | | | | | | |
Collapse
|
88
|
Abstract
OBJECTIVE Hypoxic ischemic encephalopathy (HIE) is common in children, and providing accurate and timely prognostic information is important in determining the appropriate level of care. While practice parameters are available for prognostication in adults, similar reviews are not available for children. This article reviews the current evidence in domains used to provide prognostic information in children with coma due to HIE. These include historical features of the event; physical exam signs; neurophysiologic studies, such as electroencephalogram and evoked potentials; and neuroimaging. DATA SOURCE A literature search of MEDLINE was performed using the search terms HIE and prognosis cross-referenced in series with specific domains used to provide prognostic information, including physical examination, electroencephalogram, evoked potentials, neuroimaging, and magnetic resonance imaging. The results of these searches were scanned by the authors to identify articles pertaining to children (nonneonates). Further literature was identified from the reference lists of the literature identified by MEDLINE search. Clinical, preclinical, and review articles were identified that were related to the current understanding of prognosis in pediatric HIE. Only literature in English was reviewed. RESULTS When performed at least 24 hrs after the inciting event, abnormal exam signs (pupil reactivity and motor response), absent N20 waves bilaterally on somatosensory evoked potentials, electrocerebral silence or burst suppression patterns on electroencephalogram (not due to metabolic or medication etiology), and abnormal magnetic resonance imaging with diffusion restriction in the cortex and basal ganglia are each highly predictive of poor outcome. Combining these modalities improves the overall predictive value. CONCLUSIONS All testing provides the best prognostic information several days after hypoxic-ischemic injury, and often multiple tests are required to improve prognostic ability and rule out potentially confounding conditions. Thus, when decisions can be postponed several days, neurologic consultation and testing can provide the best prognostic information to families.
Collapse
|
89
|
|
90
|
Adams JA, Bassuk JA, Arias J, Wu H, Jorapur V, Lamas GA, Kurlansky P. Periodic acceleration (pGz) CPR in a swine model of asphyxia induced cardiac arrest. Short-term hemodynamic comparisons. Resuscitation 2007; 77:132-8. [PMID: 18164796 DOI: 10.1016/j.resuscitation.2007.10.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2007] [Revised: 10/12/2007] [Accepted: 10/26/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asphyxia is one of the most common causes of pediatric cardiac arrest, and becoming a more frequently recognized cause in adults. Periodic acceleration (pGz) is a novel method of cardiopulmonary resuscitation (CPR). pGz is achieved by rapid motion of the supine body headward-footward that generates adequate perfusion and ventilation during cardiac arrest. In a swine ventricular fibrillation cardiac arrest model, pGz produced a higher return of spontaneous circulation (ROSC), superior neurological outcome, less echocardiography evidence of post resuscitation myocardial stunning, and decreased indices of tissue injury. In contrast to standard chest compression CPR, pGz does not produce rib fractures. We investigated the feasibility of pGz in severe asphyxia cardiac arrest and assessed whether beneficial effects seen in the VF model of cardiac arrest could be realized. METHODS AND RESULTS Sixteen swine weight 4+/-1 kg were anesthetized, tracheally intubated, and instrumented to measure, hemodynamics and echocardiography. Asphyxia was induced by occlusion of the tracheal tube. After loss of aortic pulsations (median time 10 min) animals were observed for three additional minutes following which all were in cardiac arrest. The animals were then randomized to receive 10 min of pGz or standard chest compression ventilation performed with a commercial device (Thumper). A single dose of epinephrine (adrenaline) and sodium bicarbonate were given and defibrillation attempted if appropriate for a maximum of 10 min. Both groups received fractional inspired O2 concentration of 100% during CPR and after resuscitation. Four animals in each group (50%) had an initial ROSC, however only two of the four initial survivors remained alive 3h after ROSC. There were no significant differences in blood pressure, coronary perfusion pressure during CPR and after early ROSC between groups. pGz treated animals had significantly lower pulmonary artery pressure; 20+/-4 mmHg compared to Thumper 46+/-5 mmHg, 30 min after ROSC (p<0.01). Surviving animals in both groups had severe myocardial dysfunction at 30 min after ROSC. At necropsy, 25% of the Thumper treated animals had rib fractures, while none occurred in the pGz group. CONCLUSIONS In a lethal model of asphyxia cardiac arrest, pGz is equivalent to standard CPR, with respect to acute outcomes and resuscitation survival rates but is associated with significantly lower pulmonary artery pressures and does not produce traumatic rib fractures.
Collapse
Affiliation(s)
- Jose A Adams
- Mt Sinai Medical Center, Division of Neonatology, Miami Beach, FL 33140, United States.
| | | | | | | | | | | | | |
Collapse
|
91
|
Thiagarajan RR, Laussen PC, Rycus PT, Bartlett RH, Bratton SL. Extracorporeal membrane oxygenation to aid cardiopulmonary resuscitation in infants and children. Circulation 2007; 116:1693-700. [PMID: 17893278 DOI: 10.1161/circulationaha.106.680678] [Citation(s) in RCA: 255] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been used to support cardiorespiratory function during pediatric cardiopulmonary resuscitation (CPR). We report on outcomes and predictors of in-hospital mortality after ECMO used to support CPR (E-CPR). METHODS AND RESULTS Outcomes for patients aged <18 years using E-CPR were analyzed with data from the Extracorporeal Life Support Organization, and predictors of in-hospital mortality were determined. Of 26,242 ECMO uses reported, 695 (2.6%) were for E-CPR (n=682 patients). Survival to hospital discharge was 38%. In a multivariable model, pre-ECMO factors such as cardiac disease (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.31 to 0.82) and neonatal respiratory disease (OR 0.28, 95% CI 0.12 to 0.66), white race (OR 0.65, 95% CI 0.45 to 0.94), and pre-ECMO arterial blood pH >7.17 (OR 0.50, 95% CI 0.30 to 0.84) were associated with decreased odds of mortality. During ECMO, renal dysfunction (OR 1.89, 95% CI 1.17 to 3.03), pulmonary hemorrhage (OR 2.23, 95% CI 1.11 to 4.50), neurological injury (OR 2.79, 95% CI 1.55 to 5.02), CPR during ECMO (OR 3.06, 95% CI 1.42 to 6.58), and arterial blood pH <7.2 (OR 2.23, 95% CI 1.23 to 4.06) were associated with increased odds of mortality. CONCLUSIONS ECMO used to support CPR rescued one third of patients in whom death was otherwise certain. Patient diagnosis, absence of severe metabolic acidosis before ECMO support, and uncomplicated ECMO course were associated with improved survival.
Collapse
Affiliation(s)
- Ravi R Thiagarajan
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
| | | | | | | | | |
Collapse
|
92
|
Zenker P, Schlesinger A, Hauck M, Spencer S, Hellmich T, Finkelstein M, Thygeson MV, Billman G. Implementation and Impact of a Rapid Response Team in a Children’s Hospital. Jt Comm J Qual Patient Saf 2007; 33:418-25. [PMID: 17711144 DOI: 10.1016/s1553-7250(07)33048-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Like the previous two studies of RRS implementation in a children's hospital, this study--the first to use an RRT model--showed a decrease in the incidence of arrests (although not at a significant level). Low mortality rates and infrequent arrests in children's hospitals make changes in these measures insensitive indicators of the positive impact of RRT implementation. RRTs provide an immediate response for children whose clinical condition is worrisome and whose attending physicians are not immediately present. Children receive significant care through the RRT, and nurse response is very favorable to having access to fast, dependable, and knowledgeable backup 24 hours a day. The RRT program is a vital component of the safety net for children's hospitals, and RRT data provides an avenue for quality improvement efforts and further research.
Collapse
Affiliation(s)
- Paul Zenker
- Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, USA
| | | | | | | | | | | | | | | |
Collapse
|
93
|
Goff DC, Brass L, Braun LT, Croft JB, Flesch JD, Fowkes FGR, Hong Y, Howard V, Huston S, Jencks SF, Luepker R, Manolio T, O'Donnell C, Robertson RM, Rosamond W, Rumsfeld J, Sidney S, Zheng ZJ. Essential features of a surveillance system to support the prevention and management of heart disease and stroke: a scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Stroke, and Cardiovascular Nursing and the Interdisciplinary Working Groups on Quality of Care and Outcomes Research and Atherosclerotic Peripheral Vascular Disease. Circulation 2006; 115:127-55. [PMID: 17179025 DOI: 10.1161/circulationaha.106.179904] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|