Part 10: Pediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

Characterization of extracorporeal membrane oxygenation for pediatric cardiac arrest in the United States: analysis of the kids' inpatient database

To characterize the overall use, cost, and outcomes of extracorporeal membrane oxygenation (ECMO) as an adjunct to cardiopulmonary resuscitation (CPR) among hospitalized infants and children in the United States, retrospective analysis of the 2000, 2003, and 2006 Kids' Inpatient Database (KID) was performed. All CPR episodes were identified; E-CPR was defined as ECMO used on the same day as CPR. Channeling bias was decreased by developing propensity scores representing the likelihood of requiring E-CPR. Univariable, multivariable, and propensity-matched analyses were performed to characterize the influence of E-CPR on survival. There were 8.6 million pediatric hospitalizations and 9,000 CPR events identified in the database. ECMO was used in 82 (0.9 %) of the CPR events. Median hospital charges for E-CPR survivors were $310,824 [interquartile range (IQR) 263,344-477,239] compared with $147,817 (IQR 62,943-317,553) for propensity-matched conventional CPR (C-CPR) survivors. Median LOS for E-CPR survivors (31 days) was considerably greater than that of propensity-matched C-CPR survivors (18 days). Unadjusted E-CPR mortality was higher relative to C-CPR (65.9 vs. 50.9 %; OR 1.9, 95 % confidence interval 1.2-2.9). Neither multivariable analysis nor propensity-matched analysis identified a significant difference in survival between groups. E-CPR is infrequently used for pediatric in-hospital cardiac arrest. Median LOS and charges are considerably greater for E-CPR survivors with C-CPR survivors. In this retrospective administrative database analysis, E-CPR did not significantly influence survival. Further study is needed to improve outcomes and to identify patients most likely to benefit from this resource-intensive therapy.

Chest compression quality over time in pediatric resuscitations

BACKGROUND

Chest compression (CC) quality deteriorates with time in adults, possibly because of rescuer fatigue. Little data exist on compression quality in children or on work done to perform compressions in general. We hypothesized that compression quality, work, and rescuer fatigue would differ in child versus adult manikin models.

METHODS

This was a prospective randomized crossover study of 45 in-hospital rescuers performing 10 minutes of single-rescuer continuous compressions on each manikin. An accelerometer recorded compression quality measures over 30-second epochs. Work and power were calculated from recorded force data. A modified visual analogue scale measured fatigue. Data were analyzed by using linear mixed-effects models and Cox regression analysis.

RESULTS

A total of 88 484 compression cycles were analyzed. Percent adequate CCs/epoch (rate ≥ 100/minute, depth ≥ 38 mm) fell over 10 minutes (child: from 85.1% to 24.6%, adult: from 86.3% to 35.3%; P = .15) and were <70% in both by 2 minutes. Peak work per compression cycle was 13.1 J in the child and 14.3 J in the adult (P = .06; difference, 1.2 J; 95% confidence interval, -0.05 to 2.5). Peak power output was 144.1 W in the child and 166.5 W in the adult (P < .001; difference, 22.4 W, 95% confidence interval, 9.8-35.0).

CONCLUSIONS

CC quality deteriorates similarly in child and adult manikin models. Peak work per compression cycle is comparable in both. Peak power output is analogous to that generated during intense exercise such as running. CC providers should switch every 2 minutes as recommended by current guidelines.

Expanding the availability of extracorporeal cardiopulmonary resuscitation

A healthy 14-year-old presented to an emergency department in Alaska, complaining of shortness of breath, chest pain, and 72 hours of malaise and headache. On admission, her blood pressure was 80/50 mm Hg, and she had cool extremities. Electrocardiography revealed wide-complex ventricular tachycardia. She underwent synchronized electrical cardioversion. Although she initially converted to sinus rhythm, she subsequently became pulseless, with electrocardiographic evidence of ventricular tachycardia. Despite cardiopulmonary resuscitation, she failed to achieve a perfusing rhythm. Cardiovascular surgery consultation was obtained, and she was placed on partial cardiopulmonary bypass during 2 hours of ongoing chest compressions. Cardiopulmonary bypass flow was limited by the small size of her femoral arteries. She remained in refractory ventricular tachycardia. The cardiopulmonary bypass circuit was modified for transportation of the patient via air ambulance 1500 miles to a tertiary medical center that specializes in pediatric heart failure and mechanical cardiopulmonary support. Upon arrival at the tertiary medical center, she underwent carotid artery cannulation to improve total cardiopulmonary support and percutaneous balloon atrial septostomy to facilitate left ventricular decompression. Intravenous immunoglobulin and steroids were administered to treat presumed acute fulminant viral myocarditis. Extracorporeal life support was support was successfully discontinued after 14 days, but she experienced a thromboembolic stroke. The patient was discharged on hospital day 65 with moderate generalized left-sided weakness, but she was able to ambulate with minimal assistance. She subsequently returned to school and is progressing appropriately with her peers. Cardiac function has normalized, and she remains in normal sinus rhythm.

Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia

Background

Atropine has is currently recommended to facilitate haemodynamic stability during critical care intubation. Our objective was to determine whether atropine use at induction influences ICU mortality.

Methodology/Principal Findings

A 2-year prospective, observational study of all first non-planned intubations, September 2007–9 in PICU and Intensive Care Transport team of Hôpital Robert Debré, Paris, 4 other PICUs and 5 NICUs in the Paris Region, France. Follow-up was from intubation to ICU discharge. A propensity score was used to adjust for patient specific characteristics influencing atropine prescription. 264/333 (79%) intubations were included. The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19–0.95, p = 0.04). One child died during intubation (1/264, 0.4%). Two age sub-groups of neonates (≤28 days) and older children (>28 days, <8 years) were examined. This difference in mortality arose from the higher mortality in children aged over one month when atropine was not used (propensity score adjusted OR 0.22, 95%CI 0.06–0.85, p = 0.028). No effect was seen in neonates (propensity score adjusted OR 1.3, 95%CI 0.31–5.1 p = 0.74). Using the propensity score, atropine maintained the mean heart rate 45.9 bpm above that observed when no atropine was used in neonates (95%CI 34.3–57.5, p<0.001) and 43.5 bpm for older children (95%CI 25.5–61.5 bpm, p<0.001).

Conclusions/Significance

Atropine use during induction was associated with a reduction in ICU mortality in children over one month. This effect is independent of atropine’s capacity to attenuate bradycardia during intubation which occurred similarly in neonates and older children. This result needs to be confirmed in a study using randomised methodology.

The American Heart Association's recent scientific statement on cardiac critical care: implications for pediatric practice

A writing group sponsored by the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, the Council on Clinical Cardiology, the Council on Cardiovascular Nursing, and the Council on Quality of Care and Outcomes Research of The American Heart Association has recently formulated a roadmap to meet the changing needs of the patient with cardiovascular disease requiring critical care. Although this roadmap has been formulated primarily to address the care needs of the adult with critical cardiovascular disease, it contains useful lessons pertinent to the care of the patient with pediatric and congenital cardiovascular disease. In this document, we have examined The Statement and applied its framework to the evolving field of pediatric cardiac critical care.

Medications in neonatal resuscitation: epinephrine and the search for better alternative strategies

Epinephrine remains the primary vasopressor for neonatal resuscitation complicated by asystole or prolonged bradycardia not responsive to adequate ventilation and chest compressions. Epinephrine increases coronary perfusion pressure primarily through peripheral vasoconstriction. Current guidelines recommend intravenous epinephrine administration (0.01-0.03 mg/kg). Endotracheal epinephrine administration results in unpredictable absorption. High-dose intravenous epinephrine poses additional risks and does not result in better long-term survival. Vasopressin has been considered an alternative to epinephrine in adults, but there is insufficient evidence to recommend its use in newborn infants. Future research will focus on the best sequence for epinephrine administration and chest compressions.

Does a more "physiological" infant manikin design effect chest compression quality and create a potential for thoracic over-compression during simulated infant CPR?

Poor survivability following infant cardiac arrest has been attributed to poor quality chest compressions. Current infant CPR manikins, used to teach and revise chest compression technique, appear to limit maximum compression depths (CDmax) to 40 mm. This study evaluates the effect of a more "physiological" CDmax on chest compression quality and assesses whether proposed injury risk thresholds are exceeded by thoracic over-compression. A commercially available infant CPR manikin was instrumented to record chest compressions and modified to enable compression depths of 40 mm (original; CDmax40) and 56 mm (the internal thoracic depth of a three-month-old male infant; CDmax56). Forty certified European Paediatric Life Support instructors performed two-thumb (TT) and two-finger (TF) chest compressions at both CDmax settings in a randomised crossover sequence. Chest compression performance was compared to recommended targets and compression depths were compared to a proposed thoracic over-compression threshold. Compressions achieved greater depths across both techniques using the CDmax56, with 44% of TT and 34% of TF chest compressions achieving the recommended targets. Compressions achieved depths that exceeded the proposed intra-thoracic injury threshold. The modified manikin (CDmax56) improved duty cycle compliance; however, the chest compression rate was consistently too high. Overall, the quality of chest compressions remained poor in comparison with internationally recommended guidelines. This data indicates that the use of a modified manikin (CDmax56) as a training aid may encourage resuscitators to habitually perform deeper chest compressions, whilst avoiding thoracic over-compression and thereby improving current CPR quality. Future work will evaluate resuscitator performance within a more realistic, simulated CPR environment.

Diagnosis and management of circulatory arrest in pediatric ventricular assist device patients: presentation of two cases and suggested guidelines

INTRODUCTION

Pediatric patients supported by ventricular assist devices (VADs) are becoming more common. No guidelines exist to provide an approach to diagnosis or management of circulatory arrest in these patients. We present two case reports of apparent circulatory arrest in pediatric VAD-supported patients at our institution.

DISCUSSION

Diagnosis of circulatory arrest in VAD-supported patients can be challenging, especially with non-pulsatile flow devices. Traditional methods of diagnosis, such as pulse check and blood pressure, may be unreliable. Etiology may be primary device failure though other etiologies need to be considered. Treatment of the circulatory arrest depends on the etiology and type of VAD device being used.

CONCLUSION

In the absence of strong literature on the approach to these patients, we present these case reports and our local institutional guidelines as a starting point for discussion.

American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest

AIM

To evaluate the association between cardiopulmonary resuscitation (CPR) quality and hemodynamic measurements during in-hospital pediatric cardiac arrest. We hypothesized that AHA recommended CPR rate and depth targets would be associated with systolic blood pressures≥80mmHg and diastolic blood pressures≥30mmHg.

METHODS

In children and adolescents <18 years of age who suffered a cardiac arrest with an invasive arterial catheter in place, a CPR monitoring defibrillator collected CPR data which was synchronized to arterial blood pressure (BP) tracings. Chest compression (CC) depths were corrected for mattress deflection. Generalized least squares regression estimated the association between BP and CPR quality, treated as continuous variables. Mixed-effects logistic regression estimated the association between systolic BP≥80mmHg/diastolic BP≥30mmHg and the AHA targets of depth≥38mm and/or rate≥100/min.

RESULTS

Nine arrests resulted in 4156 CCs. The median mattress corrected depth was 32mm (IQR 28-38); median rate was 111CC/min (IQR 103-120). AHA depth was achieved in 1090/4156 (26.2%) CCs; rate in 3441 (83.7%). Systolic BP≥80mmHg was attained in 2516/4156 (60.5%) compressions; diastolic≥30mmHg in 2561/4156 (61.6%). A rate≥100/min was associated with systolic BP≥80mmHg (OR 1.32; CI(95) 1.04, 1.66; p=0.02) and diastolic BP≥30mmHg (OR 2.15; CI(95) 1.65, 2.80; p<0.001). Exceeding both (rate≥100/min and depth≥38mm) was associated with systolic BP≥80mmHg (OR 2.02; CI(95) 1.45, 2.82; p<0.001) and diastolic BP≥30mmHg (OR 1.48; CI(95) 1.01, 2.15; p=0.042).

CONCLUSIONS

AHA quality targets (rate≥100/min and depth≥38mm) were associated with systolic BPs≥80mmHg and diastolic BPs≥30mmHg during CPR in children.

Hyperoxia, hypocapnia and hypercapnia as outcome factors after cardiac arrest in children

PURPOSE

Arterial hyperoxia after resuscitation has been associated with increased mortality in adults. The aim of this study was to test the hypothesis that post-resuscitation hyperoxia and hypocapnia are associated with increased mortality after resuscitation in pediatric patients.

METHODS

We performed a prospective observational multicenter hospital-based study including 223 children aged between 1 month and 18 years who achieved return of spontaneous circulation after in-hospital cardiac arrest and for whom arterial blood gas analysis data were available.

RESULTS

After return of spontaneous circulation, 8.5% of patients had hyperoxia (defined as PaO(2)>300 mm Hg) and 26.5% hypoxia (defined as PaO(2)<60 mm Hg). No statistical differences in mortality were observed when patients with hyperoxia (52.6%), hypoxia (42.4%), or normoxia (40.7%) (p=0.61). Hypocapnia (defined as PaCO(2)<30 mm Hg) was observed in 13.5% of patients and hypercapnia (defined as PaCO(2)>50 mm Hg) in 27.6%. Patients with hypercapnia or hypocapnia had significantly higher mortality (59.0% and 50.0%, respectively) than patients with normocapnia (33.1%) (p=0.002). At 24h after return of spontaneous circulation, neither PaO(2) nor PaCO(2) values were associated with mortality. Multiple logistic regression analysis showed that hypercapnia (OR, 3.27; 95% CI, 1.62-6.61; p=0.001) and hypocapnia (OR, 2.71; 95% CI, 1.04-7.05; p=0.04) after return of spontaneous circulation were significant mortality factors.

CONCLUSIONS

In children resuscitated from cardiac arrest, hyperoxemia after return of spontaneous circulation or 24h later was not associated with mortality. On the other hand, hypercapnia and hypocapnia were associated with higher mortality than normocapnia.

Dexmedetomidine: therapeutic use for the termination of reentrant supraventricular tachycardia

OBJECTIVES

The current drug of choice for reentrant supraventricular tachycardia (SVT) is adenosine followed by verapamil or diltiazem. Although limitations and significant adverse events have been encountered over the years, an alternative effective and safe agent has not been available. Dexmedetomidine has recently been shown to have potential antiarrhythmic effects, and here we describe our experience in the acute termination of reentrant SVT.

DESIGN

Retrospective case series.

SETTING

Quaternary University Children's Hospital, Cardiac Intensive Care Unit.

PATIENTS

Patients who received dexmedetomidine for SVT in the past 5 years.

INTERVENTIONS

None.

OUTCOME MEASURES

SVT episodes terminated with dexmedetomidine were compared with episodes terminated with adenosine.

RESULTS

Fifteen patients, median age of 10 days (6-16), were given 27 doses of dexmedetomidine, mean dose 0.7 ± 0.3 mcg/kg, for a total of 27 episodes of SVT. Successful termination occurred in 26 episodes (96%) at a median time of 30 seconds (20-35). Duration of sinus pause was 0.6 ± 0.2 seconds, there was one episode of hypotension and no bradycardia and sedation lasted for 34 ± 8 minutes. Five patients received 27 doses of adenosine, with an overall successful cardioversion in 17 patients (63%) (P= .0017). Transient bradycardia and hypotension was seen in three patients (11%), agitation in 16 patients (59%), and broncospasm in one patient. Median sinus pause was 2.5 seconds (2-9) (P < .001).

CONCLUSIONS

Dexmedetomidine appears to have novel antiarrhythmic properties for the acute termination of reentrant SVT. Although adenosine is very effective, dexmedetomidine may prove to possess a more favorable therapeutic profile with increased effectiveness and fewer side effects.

Comparison of times of intervention during pediatric CPR maneuvers using ABC and CAB sequences: a randomized trial

BACKGROUND

The proposed introduction of the CAB (circulation, airway, breathing) sequence for cardiopulmonary resuscitation has raised some perplexity within the pediatric community. We designed a randomized trial intended to verify if and how much timing of intervention in pediatric cardiopulmonary resuscitation is affected by the use of the CAB vs. the ABC (airway, breathing, circulation) sequence.

PATIENTS AND METHODS

340 volunteers, paired into 170 two-person teams, performed 2-rescuer healthcare provider BLS with both a CAB and ABC sequence. Their performances were audio-video recorded and times of intervention in the two scenarios, cardiac and respiratory arrest, were monitored.

RESULTS

The CAB sequence compared to ABC prompts quicker recognition of respiratory (CAB vs. ABC=17.48 ± 2.19 vs. 19.17 ± 2.38s; p<0.05) or cardiac arrest (CAB vs. ABC=17.48 ± 2.19 vs. 41.67 ± 4.95; p<0.05) and faster start of ventilatory maneuvers (CAB vs. ABC=19.13 ± 1.47s vs. 22.66 ± 3.07; p<0.05) or chest compressions (CAB vs. ABC=19.27 ± 2.64 vs. 43.40 ± 5.036; p<0.05).

CONCLUSIONS

Compared to ABC the CAB sequence prompts shorter time of intervention both in diagnosing respiratory or cardiac arrest and in starting ventilation or chest compression. However, this does not necessarily entail prompter resumption of spontaneous circulation and significant reduction of neurological sequelae, an issue that requires further studies.

Evaluation of a new pediatric intraosseous needle insertion device for low-resource settings

BACKGROUND AND PURPOSE

The Near Needle Holder (NNH) (Near Manufacturing, Camrose, Alberta, Canada) is a reusable tool to introduce a standard hollow needle for pediatric intraosseous (IO) infusion. We compared the NNH to the Cook Dieckmann (Cook Critical Care, Bloomington, IN) manual IO needle in a simulation setting.

METHODS

Study subjects were 32 physicians, nurses, and medical students participating in a trauma course in Guyana. After watching a training video and practicing under supervision, subjects were observed inserting each device into a pediatric leg model using a randomized crossover design. Outcome measures were time to successful insertion, technical complications, ease of use, and safety of each device.

RESULTS

The mean time for IO insertion (32 ± 13 seconds) was similar for both devices (P = .92). Subjects rated the NNH device equivalent in ease of use to the Cook IO needle but slightly lower in perceived safety to the user.

CONCLUSIONS

After training, all subjects successfully inserted the NNH IO device in a simulation environment, and most rated it as easy to use and safe. The NNH is a significant advance because IO needles are often not available in emergency departments in developing countries. Further studies are needed to evaluate clinical effectiveness of the NNH.

Improving outcomes from out-of-hospital cardiac arrest in young children and adolescents

Out-of-hospital cardiac arrest (OHCA) is an unusual but devastating occurrence in a young person. Years of life-lost are substantial and long-term health care costs of survivors can be high. However, there have been noteworthy improvements in cardiopulmonary resuscitation (CPR) standards, out-of hospital care, and postcardiac arrest therapies that have resulted in a several-fold improvement in resuscitation outcomes. Recent interest and research in resuscitation of children has the promise of generating improvements in the outcomes of these patients. Integrated and coordinated care in the out-of-hospital and hospital settings are required. This article will review the epidemiology of OHCA, the 2010 CPR guidelines, and developments in public access defibrillation for children.

Intraosseous vascular access for in-hospital emergency use: a systematic clinical review of the literature and analysis

Intraosseous (IO) vascular access is a viable primary alternative in patients requiring emergent vascular access in the hospital emergency department (ED) (eg, resuscitation, shock/septic shock) but is underutilized.

OBJECTIVES

This review has 3 objectives: (1) review the evidence supporting the use of IO access; (2) determine the utilization of IO access as described in the literature; and (3) assess the level of specialty society support.

METHODS

Electronic and hand searches were undertaken to identify relevant articles. English-language-only articles were identified. The Cochrane Review methodology along with data forms were used to collect and review data. The evidence evaluation process of the international consensus on emergency cardiovascular care was used to assess the evidence. Studies were combined where meta-analyses could be performed.

RESULTS

In levels 2 to 5 studies, IO access performed better versus alternative access methods on the end points of time to access and successful access. Complications appeared to be comparable to other venous access methods. Randomized controlled trials are lacking. Newer IO access technologies appear to do a better job of gaining successful access more quickly. Intraosseous access is underutilized in the ED because of lack of awareness, lack of guidelines/indications, proper training, and a lack of proper equipment.

CONCLUSIONS

Recommendations/guidelines from physician specialty societies involved in the ED setting are also lacking. Underutilization exists despite recommendations for IO access use from a number of important medical associations peripherally involved in the ED such as the American Academy of Pediatrics. To encourage the IO approach, IO product champions (as both supporter and user) in the ED are needed for prioritizing and assigning IO access use when warranted. In addition, specialty societies directly involved in emergent hospital care should develop clinical guidelines for IO use.

Resuscitation and extracorporeal life support during cardiopulmonary resuscitation following the Norwood (Stage 1) operation

The success of extracorporeal support in providing cardiopulmonary support for a variety of patients has led to use of Extracorporeal Life Support, also known as ECLS, as a rescue for patients failing conventional resuscitation. The use of Extracorporeal Life Support in circumstances of cardiac arrest has come to be termed "Extracorporeal Life Support during Cardiopulmonary Resuscitation" or "ECPR". Although Extracorporeal Life Support during Cardiopulmonary Resuscitation was originally described in patients following repair of congenital cardiac defects who suffered a sudden arrest, it has now been used in a variety of circumstances for patients both with and without primary cardiac disease. Multiple centres have reported successful use of Extracorporeal Life Support during Cardiopulmonary Resuscitation in adults and children. However, because of the cost, the complexity of the technique, and the resources required, Extracorporeal Life Support during Cardiopulmonary Resuscitation is not offered in all centres for paediatric patients with refractory cardiac arrest. The increasing success and availability of Extracorporeal Life Support during Cardiopulmonary Resuscitation in post-operative cardiac patients, coupled with the fact that patients undergoing the Norwood (Stage 1) operation can have rapid, unpredictable cardiac deterioration and arrest, has led to a steady increase in the use of Extracorporeal Life Support during Cardiopulmonary Resuscitation in this population. For Extracorporeal Life Support during Cardiopulmonary Resuscitation to be most successful, it must be deployed rapidly while the patient is undergoing excellent cardiopulmonary resuscitation. Early activation of the team that will perform cannulation could possibly shorten the duration of cardiopulmonary resuscitation and might improve survival and outcome. More research needs to be done to refine the populations and circumstances that offer the best outcome with Extracorporeal Life Support during Cardiopulmonary Resuscitation, to evaluate the ratios of cost to benefit, and establish the long-term neurodevelopmental outcomes in survivors.

Age-specific differences in outcomes after out-of-hospital cardiac arrests

OBJECTIVE

We assessed out-of-hospital cardiac arrests (OHCAs) for various pediatric age groups.

METHODS

This prospective, population-based, observational study included all emergency medical service-treated OHCAs in Osaka, Japan, between 1999 and 2006 (excluding 2004). Patients were grouped as adults (>17 years), infants (<1 year), younger children (1-4 years), older children (5-12 years), and adolescents (13-17 years). The primary outcome measure was 1-month survival with favorable neurologic outcome.

RESULTS

Of 950 pediatric OHCAs, resuscitations were attempted for 875 patients (92%; 347 infants, 203 younger children, 135 older children, and 190 adolescents). The overall incidence of nontraumatic pediatric OHCAs was 7.3 cases per 100 000 person-years, compared with 64.7 cases per 100 000 person-years for adults and 65.5 cases per 100 000 person-years for infants. Most infant OHCAs occurred in homes (93%) and were not witnessed (90%). Adolescent OHCAs often occurred outside the home (45%), were witnessed by bystanders (37%), and had shockable rhythms (18%). One-month survival was more common after nontraumatic pediatric OHCAs than adult OHCAs (8% [56 of 740 patients] vs 5% [1677 of 33 091 patients]; adjusted odds ratio: 2.26 [95% confidence interval: 1.63-3.13]). One-month survival with favorable neurologic outcome was more common among children than adults (3% [21 of 740 patients] vs 2% [648 of 33 091 patients]; adjusted odds ratio: 2.46 [95% confidence interval: 1.45-4.18]). Rates of 1-month survival with favorable neurologic outcome were 1% for infants, 2% for younger children, 2% for older children, and 11% for adolescents.

CONCLUSION

Survival and favorable neurologic outcome at 1 month were more common after pediatric OHCAs than adult OHCAs.

Chest compressions versus ventilation plus chest compressions: a randomized trial in a pediatric asphyxial cardiac arrest animal model

PURPOSE

To compare survival, oxygenation, ventilation, and hemodynamic variables achieved with chest compressions or ventilation plus chest compressions.

METHODS

This randomized experimental study was conducted in the experimental department of a university hospital. Thirty infant pigs with asphyxial cardiac arrest were randomized into two groups of cardiopulmonary resuscitation (CPR): group 1, continuous chest compressions plus non-coordinated ventilation with a mask and mechanical ventilator (inspired oxygen fraction 0.21) (VC); group 2, chest compressions only (CC). Nine minutes of basic resuscitation was performed initially in both groups, followed by advanced resuscitation. CPR was terminated on achieving return of spontaneous circulation (ROSC) or after 30 min of total resuscitation time without ROSC.

RESULTS

Three animals (18.8%) in the VC group and 1 (7.1%) in the CC group achieved ROSC (P = 0.351). Oxygenation and ventilation during basic CPR were insufficient in both groups, though they were significantly better in the VC group than in the CC group after 9 min (PaO(2), 26 vs. 19 mmHg, P = 0.008; PaCO(2), 84 vs. 101 mmHg, P = 0.05). Cerebral saturation was higher in the VC group (61%) than in the CC group (30%) (P = 0.06). There were no significant differences in mean arterial pressure.

CONCLUSIONS

Neither of the basic CPR protocols achieved adequate oxygenation and ventilation in this model of asphyxial pediatric cardiac arrest. Chest compressions plus ventilation produced better oxygenation, ventilation, and cerebral oxygenation with no negative hemodynamic effects. Survival was higher in the VC group, though the difference was not statistically significant.

Near-infrared spectroscopy as a hemodynamic monitor in critical illness

BACKGROUND

Near-infrared spectroscopy has moved from a research tool to a widely used clinical monitor in the critically ill pediatric patient over the last decade. The physiological and clinical evidence supporting this technology in practice is reviewed here.

METHODOLOGY

A search of MEDLINE and PubMed was conducted to find validation studies, controlled trials, and other reports of near-infrared spectroscopy use in children and adults in the clinical setting. Guidelines published by the American Heart Association, the American Academy of Pediatrics, and the International Liaison Committee on Resuscitation were reviewed including further review of references cited.

RESULTS

The biophysical properties of near-infrared spectroscopy devices allow measurement of capillary-venous oxyhemoglobin saturation in tissues a few centimeters beneath the surface sensor with validated accuracy in neonates, infants, and small patients. The biologic basis for the relationship of capillary-venous oxyhemoglobin saturation to cerebral injury has been described in animal and human studies. Normal ranges for cerebral and somatic capillary-venous oxyhemoglobin saturation have been described for normal newborns and infants and children with congenital heart disease and other disease states. The capillary-venous oxyhemoglobin saturation from both cerebral and somatic regions has been used to estimate mixed venous saturation and to predict biochemical shock, multiorgan dysfunction, and mortality in different populations. The relationship of cerebral capillary-venous oxyhemoglobin saturation to neuroimaging and functional assessment of outcome is limited but ongoing. Although there are numerous conflicting reports in small populations, expert opinion would suggest that special use may exist for near-infrared spectroscopy in patients with complex circulatory anatomy, with extremes of physiology, and in whom extended noninvasive monitoring is useful.

CONCLUSIONS

Class II, level B evidence supports the conclusion that near-infrared spectroscopy offers a favorable risk-benefit profile and can be effective and beneficial as a hemodynamic monitor for the care of critically patients.