251
|
Abstract
Atrial flutter (AFL) is the second most common type of tachyarrhythmia in the fetus and neonate. An atrial rate of 240 to 360 beats per minute, 2:1 atrioventricular conduction, and a "saw tooth" appearance on electrocardiogram (ECG) are characteristic. On echocardiogram, bilateral atrial dilatation is the most common finding. Treatment is dependent on the severity of symptoms; delivery is usually indicated in the case of fetal heart failure or hydrops fetalis, whereas postnatal AFL is most commonly treated with direct current cardioversion (DCC). This article presents an illustrative case in which the patient presented antenatally via abnormal nonstress testing and subsequent fetal echocardiogram that was concerning for AFL. Postnatal ECG confirmed this diagnosis and the patient received DCC on the day of birth, followed by digoxin and propranolol as maintenance therapy.
Collapse
|
252
|
Trummer G, Benk C, Klemm R, Biever P, Kalbhenn J, Schmutz A, Wengenmayer T, Beyersdorf F. Short-term heart and lung support: extracorporeal membrane oxygenation and extracorporeal life support. Multimed Man Cardiothorac Surg 2015; 2013:mmt008. [PMID: 24413007 DOI: 10.1093/mmcts/mmt008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In the last few years, progress in engineering has helped to develop minimized systems for extracorporeal membrane oxygenation and circulatory support. However, despite progress in engineering, the use of these systems still requires a trained team with special skills to be a beneficial and safe tool in the care of critically ill patients. The described indications and proceedings are based on the daily experience of the Freiburg group using these systems both on site in our own hospital and for transport purposes from primary care hospitals into our center of maximum care. The aim of this review is to share our hands-on experience in urgent/emergent implantations and therefore contribute to the knowledge within the growing community of users in this specialized field of extracorporeal support.
Collapse
Affiliation(s)
- Georg Trummer
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | | | | | | | | | | | | | | |
Collapse
|
253
|
Laryngoscopic options for pediatric intubation during CPR-the authors respond. Am J Emerg Med 2015; 33:1312-3. [DOI: 10.1016/j.ajem.2015.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 05/26/2015] [Indexed: 11/19/2022] Open
|
254
|
Comparatively Evaluating Medication Preparation Sequences for Treatment of Hyperkalemia in Pediatric Cardiac Arrest: A Prospective, Randomized, Simulation-Based Study. Pediatr Crit Care Med 2015; 16:e224-30. [PMID: 26181299 DOI: 10.1097/pcc.0000000000000497] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether time to prepare IV medications for hyperkalemia varied by 1) drug, 2) patient weight, 3) calcium salt, and 4) whether these data support the Advanced Cardiac Life Support recommended sequence. DESIGN Prospective randomized simulation-based study. SETTING Single pediatric tertiary medical referral center. SUBJECTS Pediatric nurses and adult or pediatric pharmacists. INTERVENTIONS Subjects were randomized to prepare medication doses for one of four medication sequences and stratified by one of three weight categories representative of a neonate/infant, child, or adult-sized adolescent: 4, 20, and 50 kg. Using provided supplies and dosing references, subjects prepared doses of calcium chloride, calcium gluconate, sodium bicarbonate, and regular insulin with dextrose. Because insulin and dextrose are traditionally prepared and delivered together, they were analyzed as one drug. Subjects preparing medications were video-recorded for the purpose of extracting timing data. MEASUREMENTS AND MAIN RESULTS A total of 12 nurses and 12 pharmacists were enrolled. The median (interquartile range) total preparation time for the three drugs was 9.5 minutes (6.4-13.7 min). Drugs were prepared significantly faster for larger children (50 kg, 6.8 min [5.6-9.1 min] vs 20 kg, 9.5 min [8.6-13.0 min] vs 4 kg, 16.3 min [12.7-18.9 min]; p = 0.001). Insulin with dextrose took significantly longer to prepare than the other medications, and there was no difference between the calcium salts: (sodium bicarbonate, 1.9 [0.8-2.6] vs calcium chloride, 2.1 [1.2-3.1] vs calcium gluconate, 2.4 [2.1-3.0] vs insulin with dextrose, 5.1 min [3.7-7.7 min], respectively; p < 0.001). Forty-two percent of subjects (10/24) made at least one dosing error. CONCLUSIONS Medication preparation for hyperkalemia takes significantly longer for smaller children and preparation of insulin with dextrose takes the longest. This study supports Pediatric Advanced Life Support guidelines to treat hyperkalemia during pediatric cardiac arrest similar to those recommended per Advanced Cardiac Life Support (i.e., first, calcium; second, sodium bicarbonate; and third, insulin with dextrose).
Collapse
|
255
|
Pentax Airway Scope AWS-S200 video laryngoscope for child tracheal intubation in a manikin study with 3 airway scenarios. Am J Emerg Med 2015; 33:1171-4. [DOI: 10.1016/j.ajem.2015.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 05/14/2015] [Accepted: 05/14/2015] [Indexed: 11/22/2022] Open
|
256
|
Mittiga MR, Rinderknecht AS, Kerrey BT. A Modern and Practical Review of Rapid-Sequence Intubation in Pediatric Emergencies. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2015. [DOI: 10.1016/j.cpem.2015.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
257
|
Prekker ME, Delgado F, Shin J, Kwok H, Johnson NJ, Carlbom D, Grabinsky A, Brogan TV, King MA, Rea TD. Pediatric Intubation by Paramedics in a Large Emergency Medical Services System: Process, Challenges, and Outcomes. Ann Emerg Med 2015; 67:20-29.e4. [PMID: 26320522 DOI: 10.1016/j.annemergmed.2015.07.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 06/27/2015] [Accepted: 07/01/2015] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE Pediatric intubation is a core paramedic skill in some emergency medical services (EMS) systems. The literature lacks a detailed examination of the challenges and subsequent adjustments made by paramedics when intubating children in the out-of-hospital setting. We undertake a descriptive evaluation of the process of out-of-hospital pediatric intubation, focusing on challenges, adjustments, and outcomes. METHODS We performed a retrospective analysis of EMS responses between 2006 and 2012 that involved attempted intubation of children younger than 13 years by paramedics in a large, metropolitan EMS system. We calculated the incidence rate of attempted pediatric intubation with EMS and county census data. To summarize the intubation process, we linked a detailed out-of-hospital airway registry with clinical records from EMS, hospital, or autopsy encounters for each child. The main outcome measures were procedural challenges, procedural success, complications, and patient disposition. RESULTS Paramedics attempted intubation in 299 cases during 6.3 years, with an incidence of 1 pediatric intubation per 2,198 EMS responses. Less than half of intubations (44%) were for patients in cardiac arrest. Two thirds of patients were intubated on the first attempt (66%), and overall success was 97%. The most prevalent challenge was body fluids obscuring the laryngeal view (33%). After a failed first intubation attempt, corrective actions taken by paramedics included changing equipment (33%), suctioning (32%), and repositioning the patient (27%). Six patients (2%) experienced peri-intubation cardiac arrest and 1 patient had an iatrogenic tracheal injury. No esophageal intubations were observed. Of patients transported to the hospital, 86% were admitted to intensive care and hospital mortality was 27%. CONCLUSION Pediatric intubation by paramedics was performed infrequently in this EMS system. Although overall intubation success was high, a detailed evaluation of the process of intubation revealed specific challenges and adjustments that can be anticipated by paramedics to improve first-pass success, potentially reduce complications, and ultimately improve clinical outcomes.
Collapse
Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine and Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | | | - Jenny Shin
- Emergency Medical Services Division, Public Health-Seattle & King County, Seattle, WA
| | - Heemun Kwok
- Division of Emergency Medicine, University of Washington, Seattle, WA
| | - Nicholas J Johnson
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA
| | - David Carlbom
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA
| | | | - Thomas V Brogan
- Division of Pediatric Critical Care Medicine, University of Washington and Seattle Children's Hospital, Seattle, WA
| | - Mary A King
- Division of Pediatric Critical Care Medicine, University of Washington and Seattle Children's Hospital, Seattle, WA
| | - Thomas D Rea
- Emergency Medical Services Division, Public Health-Seattle & King County, Seattle, WA
| |
Collapse
|
258
|
Andersen LW, Berg KM, Saindon BZ, Massaro JM, Raymond TT, Berg RA, Nadkarni VM, Donnino MW. Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA 2015; 314:802-10. [PMID: 26305650 PMCID: PMC6191294 DOI: 10.1001/jama.2015.9678] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown. OBJECTIVE To determine whether time to first epinephrine dose is associated with outcomes in pediatric in-hospital cardiac arrest. DESIGN, SETTING AND PARTICIPANTS We performed an analysis of data from the Get With the Guidelines-Resuscitation registry. We included US pediatric patients (age <18 years) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least 1 dose of epinephrine. A total of 1558 patients (median age, 9 months [interquartile range [IQR], 13 days-5 years]) were included in the final cohort. EXPOSURE Time to epinephrine, defined as time in minutes from recognition of loss of pulse to the first dose of epinephrine. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC), survival at 24 hours, and neurological outcome. A favorable neurological outcome was defined as a score of 1 to 2 on the Pediatric Cerebral Performance Category scale. RESULTS Among the 1558 patients, 487 (31.3%) survived to hospital discharge. The median time to first epinephrine dose was 1 minute (IQR, 0-4; range, 0-20; mean [SD], 2.6 [3.4] minutes). Longer time to epinephrine administration was associated with lower risk of survival to discharge in multivariable analysis (multivariable-adjusted risk ratio [RR] per minute delay, 0.95 [95% CI, 0.93-0.98]). Longer time to epinephrine administration was also associated with decreased risk of ROSC (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.96-0.99]), decreased risk of survival at 24 hours (multivariable-adjusted RR per minute delay, 0.97 [95% CI, 0.95-0.99]), and decreased risk of survival with favorable neurological outcome (multivariable-adjusted RR per minute delay, 0.95 [95% CI, 0.91-0.99]). Patients with time to epinephrine administration of longer than 5 minutes (233/1558) compared with those with time to epinephrine of 5 minutes or less (1325/1558) had lower risk of in-hospital survival to discharge (21.0% [49/233] vs 33.1% [438/1325]; multivariable-adjusted RR, 0.75 [95% CI, 0.60-0.93]; P = .01). CONCLUSIONS AND RELEVANCE Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, ROSC, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome.
Collapse
Affiliation(s)
- Lars W Andersen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts2Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Katherine M Berg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Brian Z Saindon
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joseph M Massaro
- Harvard Clinical Research Institute, Boston, Massachusetts5Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Tia T Raymond
- Division of Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, Texas
| | - Robert A Berg
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts3Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | |
Collapse
|
259
|
Garcia Guerra G, Zorzela L, Robertson CMT, Alton GY, Joffe AR, Moez EK, Dinu IA, Ross DB, Rebeyka IM, Lequier L. Survival and neurocognitive outcomes in pediatric extracorporeal-cardiopulmonary resuscitation. Resuscitation 2015; 96:208-13. [PMID: 26303570 DOI: 10.1016/j.resuscitation.2015.07.034] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Extracorporeal Cardiopulmonary Resuscitation (E-CPR) is the initiation of extracorporeal life support during active chest compressions. There are no studies describing detailed neurocognitive outcomes of this population. We aim to describe the survival and neurocognitive outcomes of children who received E-CPR. METHODS Prospective cohort study. Children who received E-CPR at the Stollery Children's Hospital between 2000 and 2010 were included. Neurocognitive follow-up, including Wechsler Preschool and Primary Scales of Intelligence, was completed at the age of 4.5 years, and at a minimum of 6 months after the E-CPR admission. RESULTS Fifty-five patients received E-CPR between 2000 and 2010. Children with cardiac disease had a 49% survival to hospital discharge and 43% survival at age 5-years, with no survivors (n=4) in those with non-cardiac disease. Pediatric E-CPR survivors had a mean (SD) Full Scale Intelligence quotient (FSIQ) score of 76.5 (15.9); with 4 children (24%) having intellectual disability (defined as FSIQ over 2 standard deviations below the population mean; i.e., <70). Multiple Cox regression analysis found that mechanical ventilation prior to E-CPR, open chest CPR, longer duration of CPR, low pH and more red blood cells given on the first day of ECMO, and longer time for lactate to normalize on ECMO were associated with higher mortality at age 5-years. CONCLUSION Pediatric patients with cardiac disease who required E-CPR had 43% survival at age 5 years. Of concern, the intelligence quotient in E-CPR survivors was significantly lower than the population mean, with 24% having intellectual disability.
Collapse
Affiliation(s)
| | - Liliane Zorzela
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Charlene M T Robertson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - Gwen Y Alton
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Ari R Joffe
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | - Irina A Dinu
- School of Public Health, University of Alberta, Edmonton, AB, Canada; Pediatric Rehabilitation Outcomes Evaluation and Research Unit, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
| | - David B Ross
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Ivan M Rebeyka
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Laurance Lequier
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
260
|
Perioperative Care of Children with Eisenmenger Syndrome Undergoing Non-cardiac Surgery. Pediatr Cardiol 2015; 36:1120-8. [PMID: 25958153 DOI: 10.1007/s00246-015-1184-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
Abstract
The Eisenmenger syndrome (ES) is a severe form of pulmonary arterial hypertension and arises in congenital heart disease with a systemic-to-pulmonary shunt. Patients with ES have multisystem involvement as a result of chronic hypoxemia with hematologic, skeletal, renal, and neurologic systems, causing significant morbidity and mortality. In contrast to pulmonary arterial hypertension, survival prospects are far superior in patients with ES and a growing number of ES patients are surviving into adulthood. As a result, many face the prospect of incidental surgery. To date, there is no guideline for the perioperative care of ES patients in children and limited data available for adult patients. This review provides an overview of appropriate measures for the safe perioperative care of patients, based on an understanding of the pathophysiological changes that occur in ES.
Collapse
|
261
|
Backeljauw B, Holland SK, Altaye M, Loepke AW. Cognition and Brain Structure Following Early Childhood Surgery With Anesthesia. Pediatrics 2015; 136:e1-12. [PMID: 26055844 PMCID: PMC4485006 DOI: 10.1542/peds.2014-3526] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Anesthetics induce widespread cell death, permanent neuronal deletion, and neurocognitive impairment in immature animals, raising substantial concerns about similar effects occurring in young children. Epidemiologic studies have been unable to sufficiently address this concern, in part due to reliance on group-administered achievement tests, inability to assess brain structure, and limited control for confounders. METHODS We compared healthy participants of a language development study at age 5 to 18 years who had undergone surgery with anesthesia before 4 years of age (n = 53) with unexposed peers (n = 53) who were matched for age, gender, handedness, and socioeconomic status. Neurocognitive assessments included the Oral and Written Language Scales and the Wechsler Intelligence Scales (WAIS) or WISC, as appropriate for age. Brain structural comparisons were conducted by using T1-weighted MRI scans. RESULTS Average test scores were within population norms, regardless of surgical history. However, compared with control subjects, previously exposed children scored significantly lower in listening comprehension and performance IQ. Exposure did not lead to gross elimination of gray matter in regions previously identified as vulnerable in animals. Decreased performance IQ and language comprehension, however, were associated with lower gray matter density in the occipital cortex and cerebellum. CONCLUSIONS The present findings suggest that general anesthesia for a surgical procedure in early childhood may be associated with long-term diminution of language abilities and cognition, as well as regional volumetric alterations in brain structure. Although causation remains unresolved, these findings nonetheless warrant additional research into the phenomenon's mechanism and mitigating strategies.
Collapse
Affiliation(s)
| | - Scott K. Holland
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mekibib Altaye
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and
| | - Andreas W. Loepke
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
262
|
Nascimento MS, Prado C, Troster EJ, Valério N, Alith MB, Almeida JFLD. Risk factors for post-extubation stridor in children: the role of orotracheal cannula. ACTA ACUST UNITED AC 2015; 13:226-31. [PMID: 26061076 PMCID: PMC4943814 DOI: 10.1590/s1679-45082015ao3255] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 01/20/2015] [Indexed: 02/07/2023]
Abstract
Objective To determine the risk factors associated with stridor, with special attention to the role of the cuffed orotracheal cannula. Methods Prospective analysis of all the intubated patients submitted to mechanical ventilator support from January 2008 to April 2011. The relevant factors for stridor collected were age, weight, size and type of airway tube, diagnosis, and duration of mechanical ventilation. The effects of variables on stridor were evaluated using uni- and multivariate logistic regression models. Results A total of 136 patients were included. Mean age was 1.4 year (3 days to 17 years). The mean duration of mechanical ventilation was 73.5 hours. Fifty-six patients (41.2%) presented with stridor after extubation. The total reintubation rate was 19.6% and 12.5 in patients with and without stridor, respectively. The duration of mechanical ventilation (>72 hours) was associated with a greater risk for stridor (odds ratio of 8.60; 95% confidence interval of 2.98-24.82; p<0.001). The presence of the cuffed orotracheal cannula was not associated with stridor (odds ratio of 98; 95% confidence interval of 0.46-2.06; p=0.953). Conclusion The main risk factor for stridor after extubation in our population was duration of mechanical ventilation. The presence of the cuffed orotracheal cannula was not associated with increased risk for stridor, reinforcing the use of the cuffed orotracheal cannula in children with respiratory distress.
Collapse
Affiliation(s)
| | | | | | - Naiana Valério
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | | |
Collapse
|
263
|
A survey demonstrating lack of consensus on the sequence of medications for treatment of hyperkalemia among pediatric critical care providers. Pediatr Crit Care Med 2015; 16:404-9. [PMID: 25734786 DOI: 10.1097/pcc.0000000000000384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hyperkalemia is one of the reversible causes of cardiac arrest in children. The Advanced Cardiovascular Life Support guidelines have specific recommendations on the choice and sequence of medications for treatment of life-threatening hyperkalemia. However, the Pediatric Advanced Life Support guidelines have no specific treatment recommendations. The objective of this study was to measure the extent to which opinions diverge among pediatricians on the choice and sequence of medication administration in the management of hyperkalemia during cardiac arrest. DESIGN Scenario-based survey. SETTING A hypothetical hospital area covered by the pediatric rapid response team. PATIENTS A hypothetical scenario of a 7-year old child receiving a blood transfusion who is suddenly unresponsive and found to be in pulseless ventricular tachycardia with stat labs revealing a potassium level of 8.3. INTERVENTIONS A scenario-based survey of PICU fellows and attendings at a PICU Fellows Boot Camp. MEASUREMENT AND MAIN RESULTS Eighty-four fellows and 24 attendings responded to the survey. The response rate was 89%. Calcium was chosen most frequently as the first drug to be administered (calcium chloride, 40/115 [34.8%]; calcium gluconate, 62/115 [53.9%]) while 38 of 115 respondents (33%) chose a drug other than calcium. Only 17 of 115 respondents (15%) would use calcium, sodium bicarbonate, insulin, and dextrose in the advanced cardiovascular life support-recommended sequence. PICU attendings were significantly more likely to administer the advanced cardiovascular life support-recommended sequence than fellows (attendings, 8/24 [33%] vs fellows, 9/84 [11%]; p = 0.007). CONCLUSION This survey revealed notable variability in the choice and sequence of medications for treatment of life-threatening hyperkalemia with surprisingly few participants in compliance with the advanced cardiovascular life support hyperkalemia guidelines. A standardized approach for pediatric life-threatening hyperkalemia is recommended to improve resuscitation quality.
Collapse
|
264
|
[Shock in infants and children]. Med Klin Intensivmed Notfmed 2015; 110:338-45. [PMID: 26022352 DOI: 10.1007/s00063-015-0035-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
Abstract
The clinical signs and symptoms of shock in newborns and children are often more subtle compared to adults. Recurring, avoidable factors for optimal outcome include failure of health care workers to recognize shock at the time of presentation. Children are able to compensate a shock state for longer periods than adults resulting in a sudden, sometimes irreversible, cardiopulmonary collapse. Different forms of shock, their therapy, and frequent errors are depicted and illustrated with practical examples. Early recognition of shock in children is crucial for optimal outcome but is not always obvious. Clinical experience, gut feeling, and careful and repeated interpretation of the vital parameters are essential to recognize and effectively treat the various forms of shock.
Collapse
|
265
|
Varvarousi G, Chalkias A, Stefaniotou A, Pliatsika P, Varvarousis D, Koutsovasilis A, Xanthos T. Intraarrest rhythms and rhythm conversion in asphyxial cardiac arrest. Acad Emerg Med 2015; 22:518-24. [PMID: 25903291 DOI: 10.1111/acem.12643] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 07/22/2014] [Accepted: 01/05/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to analyze the cardiac arrest rhythms presenting during asphyxial cardiac arrest (ACA). METHODS Asphyxial cardiac arrest was induced in 30 Landrace large white piglets, aged 12 to 15 weeks and with a mean (±SD) weight of 20 (±2) kg. After the onset of cardiac arrest, the animals were left untreated for 4 minutes, after which cardiopulmonary resuscitation was commenced. Heart rhythms were monitored from the onset of asphyxia until return of spontaneous circulation or death. RESULTS After endotracheal tube clamping and prior to cardiac arrest, normal sinus rhythm was noted in 14 animals, atrial fibrillation in two animals, Mobitz II atrioventricular block in 10 animals, and third-degree atrioventricular block in four animals. At the onset of cardiac arrest, seven animals had ventricular fibrillation (VF), two had asystole, and 21 had pulseless electrical activity (PEA). During the 4-minute period of untreated arrest, however, significant changes in the monitored rhythm were noted; at the end of the fourth minute, 19 animals had VF, two animals had asystole, and nine animals had PEA. CONCLUSIONS The most common rhythm after 4 minutes of untreated ACA was VF, while in 57% of animals, PEA was spontaneously converted to VF during the cardiac arrest interval.
Collapse
Affiliation(s)
- Giolanda Varvarousi
- The National and Kapodistrian University of Athens; Medical School, MSc Cardiopulmonary Resuscitation; Athens Greece
| | - Athanasios Chalkias
- The National and Kapodistrian University of Athens; Medical School, MSc Cardiopulmonary Resuscitation; Athens Greece
- The Hellenic Society of Cardiopulmonary Resuscitation; Athens Greece
| | - Antonia Stefaniotou
- The National and Kapodistrian University of Athens; Medical School, MSc Cardiopulmonary Resuscitation; Athens Greece
| | - Paraskevi Pliatsika
- The National and Kapodistrian University of Athens; Medical School, MSc Cardiopulmonary Resuscitation; Athens Greece
| | - Dimitrios Varvarousis
- The National and Kapodistrian University of Athens; Medical School, MSc Cardiopulmonary Resuscitation; Athens Greece
| | - Anastasios Koutsovasilis
- The National and Kapodistrian University of Athens; Medical School, MSc Cardiopulmonary Resuscitation; Athens Greece
| | - Theodoros Xanthos
- The National and Kapodistrian University of Athens; Medical School, MSc Cardiopulmonary Resuscitation; Athens Greece
- The Hellenic Society of Cardiopulmonary Resuscitation; Athens Greece
| |
Collapse
|
266
|
Hansen M, Lambert W, Guise JM, Warden CR, Mann NC, Wang H. Out-of-hospital pediatric airway management in the United States. Resuscitation 2015; 90:104-10. [PMID: 25725298 PMCID: PMC4405105 DOI: 10.1016/j.resuscitation.2015.02.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/22/2014] [Accepted: 02/06/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study was to characterize pediatric out-of-hospital airway management interventions, success rates, and complications in the United States using the 2012 National Emergency Medical Services Information System (NEMSIS) dataset. METHODS In 2012, NEMSIS collected data from Emergency Medical Services (EMS) encounters in 40 states. We included all patients less than 18 years of age and identified all patients who had airway interventions including endotracheal intubation (ETI), bag-valve-mask ventilation (BVM), continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP) and alternate airways (Combitube, King LT, Laryngeal Mask Airway (LMA), esophageal obturator airway, and cricothyroidotomy). Success and complication rates were analyzed and compared across pediatric age groups, by race, ethnicity, clinical condition, and geographic region. RESULTS We identified a total of 949,301 pediatric patient care events in the NEMSIS 2012 dataset. 4.5% had airway management procedures (42,936 events). Invasive airway management or ventilation (ETI, cricothyroidotomy, alternate airway, CPAP/BiPAP, BVM and other ventilation) took place in 1.5% of patient care events (14,107). Of those who had invasive airway management, 29.9% were less than 1 year of age, 58.1% were male, 42.3% were white, and 83.6% were in urban areas. ETI occurred in 3124 of patient care events (329 per 100,000; 95% CI 318-341). Overall success of ETI was 81.1% (95% CI 79.7-82.6). Lower success was noted in patients with cardiac arrest (75.5%, 95% CI 72.6-78.3) and those aged 1-12 months (72.1%, 95% CI 68.3-75.6). CONCLUSIONS Out-of-hospital pediatric advanced airway procedures were infrequently performed. Success rates are lowest in patients aged 1-12 months.
Collapse
Affiliation(s)
- Matthew Hansen
- Department of Emergency Medicine, Oregon Health & Science University, United States.
| | - William Lambert
- Department of Public Health & Preventive Medicine, Oregon Health & Science University, United States
| | - Jeanne-Marie Guise
- Department of Emergency Medicine, Oregon Health & Science University, United States; Department of Public Health & Preventive Medicine, Oregon Health & Science University, United States; Department of Obstetrics & Gynecology, Oregon Health & Science University, United States
| | - Craig R Warden
- Department of Emergency Medicine, Oregon Health & Science University, United States
| | - N Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, United States
| | - Henry Wang
- Department of Emergency Medicine, University of Alabama Birmingham, United States
| |
Collapse
|
267
|
Rewarming from therapeutic hypothermia induces cortical neuron apoptosis in a swine model of neonatal hypoxic-ischemic encephalopathy. J Cereb Blood Flow Metab 2015; 35:781-93. [PMID: 25564240 PMCID: PMC4420851 DOI: 10.1038/jcbfm.2014.245] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 11/08/2022]
Abstract
The consequences of therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy are poorly understood. Adverse effects from suboptimal rewarming could diminish neuroprotection from hypothermia. Therefore, we tested whether rewarming is associated with apoptosis. Piglets underwent hypoxia-asphyxia followed by normothermic or hypothermic recovery at 2 hours. Hypothermic groups were divided into those with no rewarming, rewarming at 0.5 °C/hour, or rewarming at 4 °C/hour. Neurodegeneration at 29 hours was assessed by hematoxylin and eosin staining, TUNEL assay, and immunoblotting for cleaved caspase-3. Rewarmed piglets had more apoptosis in motor cortex than did those that remained hypothermic after hypoxia-asphyxia. Apoptosis in piriform cortex was greater in hypoxic-asphyxic, rewarmed piglets than in naive/sham piglets. Caspase-3 inhibitor suppressed apoptosis with rewarming. Rapidly rewarmed piglets had more caspase-3 cleavage in cerebral cortex than did piglets that remained hypothermic or piglets that were rewarmed slowly. We conclude that rewarming from therapeutic hypothermia can adversely affect the newborn brain by inducing apoptosis through caspase mechanisms.
Collapse
|
268
|
Gupta P, Rettiganti M, Gossett JM, Kuo K, Chow V, Dao DT, Roth SJ. Association of presence and timing of invasive airway placement with outcomes after pediatric in-hospital cardiac arrest. Resuscitation 2015; 92:53-8. [PMID: 25936928 DOI: 10.1016/j.resuscitation.2015.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 03/27/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Little data exist regarding the association of presence of an invasive airway before cardiac arrest or early placement of an invasive airway after cardiac arrest with outcomes in children who experience in-hospital cardiac arrest. METHODS We conducted a retrospective review of patients aged 1 day to 18 years who received cardiopulmonary resuscitation (CPR) for ≥ 1 min in any of the three intensive care units (ICUs) at a tertiary care, academic children's hospital between 2002 and 2010. Specific outcomes evaluated included survival to hospital discharge, return of spontaneous circulation (ROSC), 24-h survival, and good neurological status at hospital discharge. We fitted multivariable logistic regression models to evaluate the association between the presence of an invasive airway prior to cardiac arrest and timing of placement of an invasive airway with these outcomes. RESULTS Three hundred and ninety-one patients were included. Of these, 197 (51%) patients were already tracheally intubated before the occurrence of cardiac arrest. Median time to intubation was 6 min [interquartile range (IQR): 2, 12] among the 194 patients tracheally intubated following cardiac arrest. We found lower survival to hospital discharge among patients intubated prior to cardiac arrest (intubated vs. non-intubated group, 43% vs. 61%, p < 0.001). After adjusting for patient and event characteristics, presence of an invasive airway prior to cardiac arrest was not associated with a significant improvement in survival to hospital discharge [odds ratio (OR): 0.70, 95% confidence interval (CI): 0.42-1.16, p = 0.17], or good neurological outcomes (OR: 0.60, 95% CI: 0.34-1.05, p = 0.07). Similarly, early placement of an invasive airway after cardiac arrest was also not associated with an improvement in survival to hospital discharge (OR: 1.05, 95% CI: 0.78-1.42, p = 0.73), or good neurological outcomes (OR: 1.08, 95% CI: 0.77-1.53, p = 0.65). CONCLUSIONS Our study demonstrates that presence of an invasive airway prior to cardiac arrest or early placement of an invasive airway after cardiac arrest is not associated with an improvement in survival to hospital discharge or good neurological outcomes. Further study of the relationship between invasive airway management and survival following cardiac arrest is warranted.
Collapse
Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, United States.
| | - Mallikarjuna Rettiganti
- Biostatistics Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Jeffrey M Gossett
- Biostatistics Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Karen Kuo
- Department of Medical Education, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Vinca Chow
- Department of Medical Education, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Duy T Dao
- Department of Medical Education, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Stephen J Roth
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, CA, United States
| |
Collapse
|
269
|
Schaefer F. Peritoneal dialysis in infants: never lose sight of-and from-arterial hypotension! Perit Dial Int 2015; 35:123-4. [PMID: 25904770 DOI: 10.3747/pdi.2015.00044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Franz Schaefer
- Division of Pediatric Nephrology Center for Pediatrics and Adolescent Medicine Heidelberg, Germany
| |
Collapse
|
270
|
Buehner M, Edwards MJ. Massive Transfusion Protocols in the Pediatric Trauma Patient: An Update. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0092-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
271
|
Tessaro MO, Salant EP, Arroyo AC, Haines LE, Dickman E. Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children. Resuscitation 2015; 89:8-12. [DOI: 10.1016/j.resuscitation.2014.08.033] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/08/2014] [Accepted: 08/24/2014] [Indexed: 10/24/2022]
|
272
|
Raymond TT, Stromberg D, Stigall W, Burton G, Zaritsky A. Sodium bicarbonate use during in-hospital pediatric pulseless cardiac arrest - a report from the American Heart Association Get With The Guidelines(®)-Resuscitation. Resuscitation 2015; 89:106-13. [PMID: 25613362 PMCID: PMC6155484 DOI: 10.1016/j.resuscitation.2015.01.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 01/07/2015] [Accepted: 01/12/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite limited recommendations for using sodium bicarbonate (SB) during cardiopulmonary resuscitation (CPR), we hypothesized that SB continues to be used frequently during pediatric in-hospital cardiac arrest (IHCA) and that its use varies by hospital-specific, patient-specific, and event-specific characteristics. METHODS We analyzed 3719 pediatric (<18 years) index pulseless CPR events from the American Heart Association Get With The Guidelines-Resuscitation database from 1/2000 to 9/2010. RESULTS SB was used in 2536 (68%) of 3719 CPR events. Incidence of SB use between 2000 and 2005 vs. 2006 and 2010 was 71.1% vs. 66.2% (P=0.002). The primary outcome was survival to discharge. Secondary outcomes included 24-h survival and neurologic outcome. Multivariable logistic regression analyzed the association between SB use and outcomes. SB had increased use an ICU location, metabolic/electrolyte disturbance, prolonged CPR, pVT/VF, and concurrently with other pharmacologic interventions. Adjusting for confounding factors, SB use was associated with decreased 24-h survival (aOR 0.83, 95% CI: 0.69, 0.99) and decreased survival to discharge (aOR 0.80; 95% CI: 0.65, 0.97). Inclusion of metabolic/electrolyte abnormalities, hyperkalemia, and toxicologic abnormalities only (n=674), SB use was not associated with worse outcomes or unfavorable neurologic outcome. CONCLUSIONS SB is used frequently during pediatric pulseless IHCA, yet there is a significant trend toward less routine use over the last decade. Because SB is more likely to be used in an ICU, with prolonged CPR, and concurrently with other pharmacologic interventions; its use during CPR may be associated with poor prognosis due to an association with "last ditch" efforts of resuscitation rather than causation.
Collapse
Affiliation(s)
- Tia T. Raymond
- Department of Pediatrics and Critical Care Medicine, Section of Pediatric Cardiac Intensive Care, Medical City Children’s Hospital, Dallas, TX, United States
| | - Daniel Stromberg
- Department of Pediatrics and Critical Care Medicine, Section of Pediatric Cardiac Intensive Care, Medical City Children’s Hospital, Dallas, TX, United States
| | - William Stigall
- Department of Pediatrics and Critical Care Medicine, Section of Pediatric Cardiac Intensive Care, Medical City Children’s Hospital, Dallas, TX, United States
| | - Grant Burton
- Department of Pediatrics and Critical Care Medicine, Section of Pediatric Cardiac Intensive Care, Medical City Children’s Hospital, Dallas, TX, United States
| | - Arno Zaritsky
- Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA, United States
| | | |
Collapse
|
273
|
Rajan S, Wissenberg M, Folke F, Hansen CM, Lippert FK, Weeke P, Karlsson L, Søndergaard KB, Kragholm K, Christensen EF, Nielsen SL, Kober L, Gislason GH, Torp-Pedersen C. Out-of-hospital cardiac arrests in children and adolescents: Incidences, outcomes, and household socioeconomic status. Resuscitation 2015; 88:12-9. [DOI: 10.1016/j.resuscitation.2014.11.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 11/17/2014] [Accepted: 11/30/2014] [Indexed: 11/28/2022]
|
274
|
Mueller EL, Sabbatini A, Gebremariam A, Mody R, Sung L, Macy ML. Why pediatric patients with cancer visit the emergency department: United States, 2006-2010. Pediatr Blood Cancer 2015; 62:490-5. [PMID: 25345994 PMCID: PMC4304987 DOI: 10.1002/pbc.25288] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/05/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Little is known about emergency department (ED) use among pediatric patients with cancer. We explored reasons prompting ED visits and factors associated with hospital admission. PROCEDURE A retrospective cohort analysis of pediatric ED visits from 2006 to 2010 using the Nationwide Emergency Department Sample, the largest all-payer database of United States ED visits. Pediatric patients with cancer (ages ≤19 years) were identified using Clinical Classification Software. Proportion of visits and disposition for the top ten-ranking non-cancer diagnoses were determined. Weighted multivariate logistic regression was performed to analyze factors associated with admission versus discharge. RESULTS There were 294,289 ED visits by pediatric patients with cancer in the U.S. over the study period. Fever and fever with neutropenia (FN) were the two most common diagnoses, accounting for almost 20% of visits. Forty-four percent of pediatric patients with cancer were admitted to the same hospital, with admission rates up to 82% for FN. Risk factors for admission were: FN (odds ratio (OR) 8.58; 95% confidence interval (CI) 5.97-12.34); neutropenia alone (OR 7.28; 95% CI 5.08-10.43), ages 0-4 years compared with 15-19 years (OR 1.19; 95% CI 1.08-1.31) and highest median household income ZIP code (OR 1.27; 95% CI 1.08-1.49) compared with lowest. "Self-pay" visits had lower odds of admission (OR 0.42; 95% CI 0.35-0.51) compared with public payer. CONCLUSION FN was the most common reason for ED visits among pediatric patients with cancer and is the condition most strongly associated with admission. Socioeconomic factors appear to influence ED disposition for this population.
Collapse
Affiliation(s)
- Emily L Mueller
- Division of Pediatric Hematology Oncology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109
| | - Amber Sabbatini
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109
| | - Rajen Mody
- Division of Pediatric Hematology Oncology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109
| | - Lillian Sung
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle L Macy
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109
| |
Collapse
|
275
|
Cao D, Heard K, Foran M, Koyfman A. Intravenous Lipid Emulsion in the Emergency Department: A Systematic Review of Recent Literature. J Emerg Med 2015; 48:387-97. [DOI: 10.1016/j.jemermed.2014.10.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 10/01/2014] [Accepted: 10/12/2014] [Indexed: 10/24/2022]
|
276
|
Newmyer R, Mendelson J, Pang D, Fink EL. Targeted Temperature Management in Pediatric Central Nervous System Disease. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2015; 1:38-47. [PMID: 26042193 PMCID: PMC4450147 DOI: 10.1007/s40746-014-0008-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute central nervous system conditions due to hypoxic-ischemic encephalopathy, traumatic brain injury (TBI), status epilepticus, and central nervous system infection/inflammation, are a leading cause of death and disability in childhood. There is a critical need for effective neuroprotective therapies to improve outcome targeting distinct disease pathology. Fever, defined as patient temperature > 38°C, has been clearly shown to exacerbate brain injury. Therapeutic hypothermia (HT) is an intervention using targeted temperature management that has multiple mechanisms of action and robust evidence of efficacy in multiple experimental models of brain injury. Prospective clinical evidence for its neuroprotective efficacy exists in narrowly-defined populations with hypoxic-ischemic injury outside of the pediatric age range while trials comparing hypothermia to normothermia after TBI have failed to demonstrate a benefit on outcome but consistently demonstrate potential use in decreasing refractory intracranial pressure. Data in children from prospective, randomized controlled trials using different strategies of targeted temperature management for various outcomes are few but a large study examining HT versus controlled normothermia to improve neurological outcome in cardiac arrest is underway.
Collapse
Affiliation(s)
- Robert Newmyer
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Jenny Mendelson
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Diana Pang
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| | - Ericka L Fink
- Children's Hospital of Pittsburgh of UPMC (Pittsburgh, PA USA)
| |
Collapse
|
277
|
Saharan S, Balaji S. Cardiovascular collapse during amiodarone infusion in a hemodynamically compromised child with refractory supraventricular tachycardia. Ann Pediatr Cardiol 2015; 8:50-2. [PMID: 25684888 PMCID: PMC4322402 DOI: 10.4103/0974-2069.149519] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We describe a 7-week-old female infant who presented with refractory supraventricular tachycardia (SVT). During amiodarone infusion, she developed hypotension and cardiac arrest requiring extracorporeal membrane oxygenation (ECMO) support. After successful control of SVT using procainamide infusion, she was weaned from ECMO and discharged home on oral flecainide. We conclude that infants with acidosis, ventricular dysfunction, and prolonged refractory SVT may poorly tolerate intravenous amiodarone.
Collapse
Affiliation(s)
- Sunil Saharan
- Department of Pediatrics, Division of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, U S A
| | - Seshadri Balaji
- Department of Pediatrics, Division of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, U S A
| |
Collapse
|
278
|
Cortez E, Davis J, Keseg D. Supraventricular Tachycardia Cardioverted by an Automated External Debrillator in a 9-year-old Male with a History of Wolff-Parkinson-White Syndrome. PREHOSP EMERG CARE 2015; 19:448-50. [PMID: 25664915 DOI: 10.3109/10903127.2014.995849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Early defibrillation for cardiac arrest patients is a formidable link in the chain of survival promulgated by the American Heart Association. Automated external defibrillators (AEDs) provide public access defibrillation for out-of-hospital cardiac arrests and improve survivability. AEDs are only approved for use in patients in cardiac arrest; defibrillation may be inadvertently advised if utilized on a patient not experiencing cardiac arrest. We describe a case report of an AED cardioversion of a stable, pediatric patient with acute supraventricular tachycardia secondary to underlying Wolff-Parkinson-White syndrome. We discuss general AED principles, the cardioversion function on the particular AED used in this encounter, and the importance of community and organizational policies to encourage the correct application of AEDs.
Collapse
|
279
|
Abend NS, Mani R, Tschuda TN, Chang T, Topjian AA, Donnelly M, LaFalce D, Krauss MC, Schmitt SE, Levine JM. EEG Monitoring during Therapeutic Hypothermia in Neonates, Children, and Adults. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2011.11079816] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Nicholas S. Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ram Mani
- Penn Epilepsy Center, Department of Neurology Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Tammy N. Tschuda
- Departments of Neurology, Children's National Medical Center, Washington, DC
| | - Tae Chang
- Departments of Neurology, Children's National Medical Center, Washington, DC
| | - Alexis A. Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Maureen Donnelly
- Neurodiagnostic Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Denise LaFalce
- Neurodiagnostic Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Margaret C. Krauss
- Neurodiagnostic Laboratory, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sarah E. Schmitt
- Penn Epilepsy Center, Department of Neurology Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Joshua M. Levine
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care, Hospital of the University of Pennsylvania University of Pennsylvania School of Medicine Philadelphia, Pennsylvania
| |
Collapse
|
280
|
|
281
|
Sutton RM, Friess SH, Naim MY, Lampe JW, Bratinov G, Weiland TR, Garuccio M, Nadkarni VM, Becker LB, Berg RA. Patient-centric blood pressure-targeted cardiopulmonary resuscitation improves survival from cardiac arrest. Am J Respir Crit Care Med 2015; 190:1255-62. [PMID: 25321490 DOI: 10.1164/rccm.201407-1343oc] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Although current resuscitation guidelines are rescuer focused, the opportunity exists to develop patient-centered resuscitation strategies that optimize the hemodynamic response of the individual in the hopes to improve survival. OBJECTIVES To determine if titrating cardiopulmonary resuscitation (CPR) to blood pressure would improve 24-hour survival compared with traditional CPR in a porcine model of asphyxia-associated ventricular fibrillation (VF). METHODS After 7 minutes of asphyxia, followed by VF, 20 female 3-month-old swine randomly received either blood pressure-targeted care consisting of titration of compression depth to a systolic blood pressure of 100 mm Hg and vasopressors to a coronary perfusion pressure greater than 20 mm Hg (BP care); or optimal American Heart Association Guideline care consisting of depth of 51 mm with standard advanced cardiac life support epinephrine dosing (Guideline care). All animals received manual CPR for 10 minutes before first shock. Primary outcome was 24-hour survival. MEASUREMENTS AND MAIN RESULTS The 24-hour survival was higher in the BP care group (8 of 10) compared with Guideline care (0 of 10); P = 0.001. Coronary perfusion pressure was higher in the BP care group (point estimate +8.5 mm Hg; 95% confidence interval, 3.9-13.0 mm Hg; P < 0.01); however, depth was higher in Guideline care (point estimate +9.3 mm; 95% confidence interval, 6.0-12.5 mm; P < 0.01). Number of vasopressor doses before first shock was higher in the BP care group versus Guideline care (median, 3 [range, 0-3] vs. 2 [range, 2-2]; P = 0.003). CONCLUSIONS Blood pressure-targeted CPR improves 24-hour survival compared with optimal American Heart Association care in a porcine model of asphyxia-associated VF cardiac arrest.
Collapse
Affiliation(s)
- Robert M Sutton
- 1 Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, and
| | | | | | | | | | | | | | | | | | | |
Collapse
|
282
|
Peer SM, Emerson DA, Costello JP, Shu MK, Zurakowski D, Jonas RA, Berger JT, Nath DS. Intermediate-term results of extracorporeal membrane oxygenation support following congenital heart surgery. World J Pediatr Congenit Heart Surg 2015; 5:236-40. [PMID: 24668971 DOI: 10.1177/2150135113515495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although there are considerable data regarding in-hospital results of congenital heart surgery (CHS) patients requiring postoperative extracorporeal membrane oxygenation (ECMO) support, there is limited information on intermediate-term outcomes. METHODS A single-institution retrospective review of 25 consecutive postoperative CHS patients who required ECMO and survived to hospital discharge between January 2003 and June 2008. Survival was estimated by the Kaplan-Meier method. RESULTS At a median follow-up of 3.3 years (interquartile range: 1.2-5.9 years), there was one death which occurred at six months postsurgery. Kaplan-Meier-estimated survival at three years was 95% (95% confidence interval: 90%-100%). Indications for ECMO included extracorporeal cardiopulmonary resuscitation (48%), systemic hypoxia (4%), postoperative low-cardiac output syndrome (28%), and intraoperative failure to wean off cardiopulmonary bypass (20%). Following ECMO support, 65% of patients had unplanned cardiac reinterventions (three requiring operative interventions, six requiring percutaneous interventions, and four requiring both), and 47% of patients required unplanned hospitalizations. In all, 29% of patients developed neurological deficits and 12% of patients developed chronic respiratory failure. No patients developed renal failure. Overall, systemic ventricular (SV) function normalized in 83% of patients, whereas 17% of patients had persistent mild-to-moderate SV dysfunction. CONCLUSIONS Intermediate-term patient survival of ECMO following CHS is encouraging. However, neurological impairment and unplanned cardiac reinterventions remain significant concerns. Further delineation of risk factors to improve patient outcomes is warranted.
Collapse
Affiliation(s)
- Syed M Peer
- Division of Cardiovascular Surgery, Children's National Medical Center, Washington, DC, USA
| | | | | | | | | | | | | | | |
Collapse
|
283
|
Kohama H, Komasawa N, Ueki R, Kaminoh Y, Nishi SI. Simulation analysis of three intubating supraglottic devices during infant chest compression. Pediatr Int 2015; 57:180-2. [PMID: 25711262 DOI: 10.1111/ped.12541] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 09/21/2014] [Accepted: 10/29/2014] [Indexed: 11/27/2022]
Abstract
Current guidelines for pediatric cardiopulmonary resuscitation suggest that supraglottic devices are alternatives for tracheal intubation with minimal interruption of chest compression. We examined the utility of three intubating supraglottic devices, air-Q® (air-Q), Ambu® aura-i (aura-i), and i-gel® (i-gel), utilizing manikin simulation. Twenty-two novice physicians performed securing of airway on an infant manikin with the three devices. We measured the rate of success on ventilation and the insertion time with or without chest compression. Successful ventilation rate did not significantly decrease with chest compression in the three devices (without chest compression: air-Q, 21/22; aura-i, 20/22; i-gel, 20/22, during chest compression: air-Q, 20/22; aura-i, 20/22; i-gel, 18/22). The insertion time with air-Q and aura-i did not extend significantly for chest compression. In contrast, the insertion time with i-gel was significantly extended in chest compression (P < 0.05). Air-Q and aura-i are more useful for airway management during chest compression than i-gel.
Collapse
Affiliation(s)
- Hanako Kohama
- Division of Intensive Care Unit, Hyogo College of Medicine, Hyogo, Japan
| | | | | | | | | |
Collapse
|
284
|
Szarpak Ł, Czyżewski Ł, Kurowski A, Truszewski Z. Comparison of the TruView PCD video laryngoscope and macintosh laryngoscope for pediatric tracheal intubation by novice paramedics: a randomized crossover simulation trial. Eur J Pediatr 2015; 174:1325-32. [PMID: 25894914 PMCID: PMC4575358 DOI: 10.1007/s00431-015-2538-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/05/2015] [Accepted: 04/02/2015] [Indexed: 12/19/2022]
Abstract
UNLABELLED The aim of the present study was to evaluate whether the TruView video laryngoscope (TruView) facilitates pediatric endotracheal intubation (ETI) more quickly and safely than conventional Macintosh laryngoscope (MAC) in three manikin-based airway scenarios. This was a randomized crossover manikin study including 120 novice paramedics. The participants performed tracheal intubations using both TruView and MAC on a pediatric manikin in a control scenario (A), chest compression scenario (B), and chest compression cervical stabilization scenario (C). The sequence of scenarios was randomized. The primary outcome was time to intubation. Secondary outcomes were overall success rates, incidence of dental trauma, and ease of intubation. All intubation attempts were assessed by a trained assistant. The overall success rate was significantly higher with the TruView compared than the MAC in scenario B (100 vs. 81.7 %; p = 0.011) and scenario C (100 vs. 68.3 %; p < 0.001). The intubation time was significantly lower with the TruView than the MAC (18.5 vs. 24.3 s, p = 0.017, for scenario A; 21.6 vs. 25.7 s, p = 0.023, for scenario B; and 28.9 vs. 45.4 s, p < 0.001, for scenario C). Glottic view quality was better with TruView than the MAC in all scenarios, p < 0.001. CONCLUSIONS The TruView offers better intubation conditions than the MAC on a pediatric manikin in the control scenario, chest compression scenario, and chest compression scenario with cervical stabilization scenario. The TruView may be used to elevate the epiglottis for orotracheal intubation. Further clinical studies are necessary to confirm these initial positive findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02289872. WHAT IS KNOWN •Prehospital pediatric intubation using a standard laryngoscope is varied and ranges from 63.4 to 82 %. What is New: •This is the first study showing efficiency of pediatric endotracheal intubation using the TruView PCD by paramedics in tree simulation scenarios. •TruView PCD offers better pediatric intubation conditions than the Macintosh laryngoscope.
Collapse
Affiliation(s)
- Łukasz Szarpak
- Department of Emergency Medicine, Medical University of Warsaw, Lindleya 4 Street 02-005, Warsaw, Poland.
| | - Łukasz Czyżewski
- Department of Anesthesiology, Institute of Cardiology, Warsaw, Poland
- Department of Nephrologic Nursing, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Kurowski
- Department of Anesthesiology, Institute of Cardiology, Warsaw, Poland
| | - Zenon Truszewski
- Department of Emergency Medicine, Medical University of Warsaw, Lindleya 4 Street 02-005, Warsaw, Poland
| |
Collapse
|
285
|
Percutaneous left atrial decompression in patients supported with extracorporeal membrane oxygenation for cardiac disease. Pediatr Crit Care Med 2015; 16:59-65. [PMID: 25319629 DOI: 10.1097/pcc.0000000000000276] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Left atrial decompression using cardiac catheterization techniques has been described at centers with extracorporeal membrane oxygenation programs. Left atrial decompression can decrease cardiogenic edema, minimize ventricular distension, and allow myocardial recovery. We describe Boston Children's Hospital's experience with percutaneous left atrial decompression techniques, acute outcomes, and clinical impact of left atrial decompression in extracorporeal membrane oxygenation patients. SUBJECTS Patients supported with extracorporeal membrane oxygenation undergoing percutaneous left atrial decompression were identified and assigned to two groups 1) myocarditis/suspected myocarditis or 2) nonmyocarditis cardiac disease. INTERVENTIONS Three techniques including vent placement, static balloon dilation, and stent implantation were used. MEASUREMENTS AND MAIN RESULTS Change in left atrial pressure and severity of pulmonary edema on chest radiography pre and post procedure, impact of timing and technique of left atrial decompression on resolution of left atrial hypertension, and extracorporeal membrane oxygenation survival were evaluated. Furthermore, we evaluated the presence of residual atrial septal defect during follow-up. Percutaneous left atrial decompression was performed in 44 of 419 extracorporeal membrane oxygenation cases (10.5%) and was frequently used for myocarditis (22 of 44 patients; 50%). Techniques included 25 vents, 17 static balloon dilations, and two stents. All techniques were equally successful and significantly reduced left atrial pressure and pulmonary edema. Survival to hospital discharge was not associated with extracorporeal membrane oxygenation duration prior to left atrial decompression, change in left atrial pressure, or technique used. Persistent atrial septal defect was noted in five surviving patients (excluding transplant recipients and deceased), two required closure. CONCLUSIONS Left atrial decompression can be performed effectively in children on extracorporeal membrane oxygenation using various percutaneous techniques. Reduction in pulmonary venous congestion is usually evident by chest radiography within 48 hours of intervention. Persistent atrial septal defect may require closure at the time of extracorporeal membrane oxygenation decannulation or during long-term follow-up.
Collapse
|
286
|
Diagnostic imaging in pediatric polytrauma management. Radiol Med 2014; 120:33-49. [PMID: 25376101 DOI: 10.1007/s11547-014-0469-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 10/29/2014] [Indexed: 01/20/2023]
Abstract
Trauma is the cause of over 45% of deaths in children aged 1 to 14 years. Since multiple injuries are common among children, the emergency physician has to assess all the organs of a high-energy injured child, independent of mechanism of the trauma. Even if the principles of polytrauma management are identical both in children and in adults, the optimal pediatric patient care requires a specific understanding of some important anatomical, physiological, and psychological differences that play a significant role in the assessment and management of a pediatric patient. Emergency Radiology already plays a crucial role in the diagnostic process of a polytraumatized child according to the primary survey, through the use of multiple imaging modalities. Radiological and Ultrasound examinations play a basic role in the hemodynamically unstable patients. In the hemodynamically stable patients whole-body CT scanning is the most immediate radiological procedure that allows the examination of all the body parts of a polytraumatized child, reducing the number of minor injuries that might otherwise be neglected.
Collapse
|
287
|
Implementation of an extracorporeal cardiopulmonary resuscitation simulation program reduces extracorporeal cardiopulmonary resuscitation times in real patients. Pediatr Crit Care Med 2014; 15:856-60. [PMID: 25162513 DOI: 10.1097/pcc.0000000000000234] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if development of an extracorporeal cardiopulmonary resuscitation simulation program reduced extracorporeal cardiopulmonary resuscitation times in real patients DESIGN : Before-after study. SETTING Twenty-six bed pediatric cardiac ICU in a tertiary urban hospital. PATIENTS Forty-three cardiac patients (aged 1 d to 16 yr) who received extracorporeal cardiopulmonary resuscitation. INTERVENTIONS An interdisciplinary team collaborated to define the roles and clarify responsibilities of each individual involved in extracorporeal cardiopulmonary resuscitation. An "ideal rapid deployment" was defined and tested using simulation sessions. This included a task analysis, role creation, and multidisciplinary simulations, including structured debriefings and video review and the creation of a master checklist. MEASUREMENTS AND MAIN RESULTS There were a total of 43 episodes of extracorporeal cardiopulmonary resuscitation during the study period, 16 (37%) of which occurred during the preintervention time period (from February 2009 to March 2010) and 27 (63%) during the postintervention time period (April 2010 to March 2013). The median deployment time in the preintervention time period was 51 minutes (interquartile range, 43-62 min), whereas the median deployment time in the postintervention time period was 40 minutes (interquartile range, 23-52 min) (p = 0.018). CONCLUSIONS There are no standard guidelines of how a team should coordinate the efforts of nursing, physicians, extracorporeal membrane oxygenation specialists, surgeons, respiratory therapists, patient care technicians, and unit clerks to emergently execute this complex procedure. Because time is of the essence, it is essential to develop a highly functioning and well-coordinated team with a standardized method of the procedure, its documentation, and communication. Simulation accomplished this for our program. Following these simulation exercises, not only was there a subjectively observed improved coordination and smoother deployment of extracorporeal membrane oxygenation in real-life extracorporeal cardiopulmonary resuscitation, but we have also demonstrated a significantly faster deployment of extracorporeal membrane oxygenation as compared with the presimulation era.
Collapse
|
288
|
Labenne M, Paut O. Arrêt cardiaque chez l’enfant : définition, épidémiologie, prise en charge et pronostic. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.jeurea.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
289
|
Hsu J, Wang CH, Huang SC, Yu HY, Chi NH, Wu IH, Chan CY, Chang CI, Wang SS, Chen YS. Clinical Applications of Extracorporeal Membranous Oxygenation: A Mini-Review. ACTA CARDIOLOGICA SINICA 2014; 30:507-13. [PMID: 27122828 DOI: 10.6515/acs20140821a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
UNLABELLED The clinical usage of extracorporeal membranous oxygenation began more than 40 years ago. Although the indications for its use have expanded over the years, it has been challenging to conduct randomized controlled trials to prove that extracorporeal membranous oxygenation is more effective than traditional approaches. Through a review of retrospective reports and data from registries, we attempted to evaluate the appropriateness of its application for acute respiratory distress syndrome, cardiopulmonary resuscitation, postcardiotomy cardiogenic shock, and sepsis. Our investigation revealed that using extracorporeal membranous oxygenation when readily available is appropriate for all patients with cardiopulmonary resuscitation or postcardiotomy cardiogenic shock, and for selected patients with acute respiratory distress syndrome or sepsis. KEY WORDS Acute respiratory distress syndrome; Cardiopulmonary resuscitation; Extracorporeal membranous oxygenation; Postcardiotomy cardiogenic shock; Sepsis.
Collapse
Affiliation(s)
- Jiun Hsu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Yunlin Branch, Douliou City, Yunlin County
| | - Chih-Hsien Wang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Shu-Chien Huang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Hsi-Yu Yu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei; ; Department of Cardiovascular Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu City, Taiwan
| | - Nai-Hsin Chi
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - I-Hui Wu
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Chih-Yang Chan
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Chung-I Chang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Shoei-Shen Wang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| | - Yih-Sharng Chen
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei
| |
Collapse
|
290
|
Abstract
Supraventricular tachycardia (SVT) is the most common arrhythmia in the pediatric population. Despite its commonality, presentation of SVT can be nonspecific and varies based upon age with infants demonstrating fussiness or irritability and older children reporting vague perceptions of tachycardia or palpitations. Furthermore, SVT may manifest as self-limited paroxysms or with prolonged runs of SVT with subsequent development of cardiac dysfunction, heart failure, and multiorgan shock. Clinicians must maintain high levels of suspicion for SVT given the potentially dire consequences of untreated SVT. When diagnosed, there are effective acute and chronic treatments for SVT, with potential for spontaneous resolution in many infants.
Collapse
|
291
|
Mauch J, Ringer S, Spielmann N, Weiss M. Impact of catecholamines in cardiac arrest due to acute asphyxia--a study in piglets. Paediatr Anaesth 2014; 24:933-9. [PMID: 24964918 DOI: 10.1111/pan.12457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Early intravenous epinephrine administration may help to achieve return of spontaneous circulation in cardiac arrest (CA). However, venous access can be challenging in small children. This study investigates the effect of intravenous and intramuscular epinephrine in treatment of asphyxial CA. METHODS Twenty-eight, 2-5-weeks-old, anesthetized piglets were asphyxiated by ventilation withdrawal. CA was untreated for 8 min, followed by 2 min of basic life support. Following this, epinephrine iv (10 μg·kg(-1) , group IV), epinephrine im (100 μg·kg(-1) , group IM), or normal saline (group NS) were administered. Further doses of epinephrine were given in group IV every 4 min, in group IM after 10 min if required. After twenty-two minutes of CA, iv epinephrine was given to all animals still in CA. Outcome measures were survival and epinephrine plasma concentrations. RESULTS Ten animals regained spontaneous circulation after 2 min of basic life support. Therefore, no drug treatment was administered (drop out). Resuscitation was effective in 2 pigs of group IM (n = 6), in 6 of group NS (n = 8) and in all of group IV (n = 4). Nonsurvivors had higher epinephrine (P < 0.01) and norepinephrine (P < 0.01) plasma concentrations prior to start of resuscitation. Median increase in epinephrine plasma concentration from T0 to T5 was 138, 134, and 29 nm in group IV, IM, and NS, respectively. CONCLUSIONS Intravenous and intramuscular administered epinephrine led to similar increase in plasma concentrations during resuscitation of asphyxial CA without hemodynamic or survival benefit. High endogenous epinephrine and norepinephrine plasma concentrations were negative predictors for survival.
Collapse
Affiliation(s)
- Jacqueline Mauch
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland; Department of Anesthesia and Perioperative Medicine, Kantonsspital Aarau, Tellstrasse, Aarau, Switzerland
| | | | | | | |
Collapse
|
292
|
Abstract
Care of the ill and injured child requires knowledge of unique pediatric anatomic and physiologic differences. Subtleties in presentation and pathophysiologic differences impact management. This article discusses pediatric resuscitation, the presentation and management of common childhood illness, pediatric trauma, and common procedures required in the critically ill child.
Collapse
|
293
|
Abstract
UNLABELLED Cardiac arrhythmias are very frequent in fetuses and newborns. The prognosis depends on the nature of the arrhythmias but is most often either spontaneously benign or following short-term medication administration. A correct diagnosis is essential for both management and prognosis. It is based on echocardiography during the fetal period and mainly on history, physical exam, and electrocardiogram after birth, but other modalities are available to record transient arrhythmic events. Irregular rhythms are mostly benign and rarely require therapy. In most fetuses and infants, tachyarrhythmias resolve spontaneously or require short-term administration of antiarrhythmics. Approximately one third of these may recur later on, especially during adolescence. Persistent bradyarrhythmias might require pacemaker implantation when associated with failure to thrive or with risk of sudden death. CONCLUSION Arrhythmias in fetuses and infants are very common and mostly benign. History, physical exam, and recording of the arrhythmia are essential to make a correct diagnosis and establish an appropriate management for the rare potentially harmful arrhythmias.
Collapse
|
294
|
Improving survival after pediatric cardiopulmonary arrest: pay attention to the details. Crit Care Med 2014; 42:1571-2. [PMID: 24836805 DOI: 10.1097/ccm.0000000000000259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
295
|
Abstract
Oxygen is one of the most frequently-used therapeutic agents in medicine and the most commonly administered drug by prehospital personnel. There is increasing evidence of harm with too much supplemental oxygen in certain conditions, including stroke, chronic obstructive pulmonary disease (COPD), neonatal resuscitations, and in postresuscitation care. Recent guidelines published by the British Thoracic Society (BTS) advocate titrated oxygen therapy, but these guidelines have not been widely adapted in the out-of-hospital setting where high-flow oxygen is the standard. This report is a description of the implementation of a titrated oxygen protocol in a large urban-suburban Emergency Medical Services (EMS) system and a discussion of the practical application of this out-of-hospital protocol.
Collapse
|
296
|
Does a resuscitation pharmacologic bundle of epinephrine, terlipressin, and corticosteroids improve outcome from asphyxial cardiac arrest? Pediatr Crit Care Med 2014; 15:573-4. [PMID: 25000425 DOI: 10.1097/pcc.0000000000000166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
297
|
Langhan ML, Kurtz JC, Schaeffer P, Asnes AG, Riera A. Experiences with capnography in acute care settings: a mixed-methods analysis of clinical staff. J Crit Care 2014; 29:1035-40. [PMID: 25129575 DOI: 10.1016/j.jcrc.2014.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 06/19/2014] [Accepted: 06/21/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Although capnography is being incorporated into clinical guidelines, it is not used to its full potential. We investigated reasons for limited implementation of capnography in acute care areas and explored facilitators and barriers to its implementation. METHODS A purposeful sample of physicians and nurses in emergency departments and intensive care units participated in semistructured interviews. Grounded theory, iterative data analysis, and the constant comparative method were used to analyze the data to inductively generate ideas and build theories. RESULTS Nineteen providers were interviewed from 5 hospitals. Six themes were identified: variability in use of capnography among acute care units, availability and accessibility of capnography equipment, the evidence behind capnography use, the impact of capnography on patient care, personal experiences impacting use of capnography, and variable knowledge about capnography. Barriers and facilitators to use were found within each theme. CONCLUSIONS We observed varied responsiveness to capnography and identified factors that work to foster or discourage its use. These data can guide future implementation strategies. A deliberate strategy to foster utilization, mitigate barriers, and broadly accelerate implementation has the potential to profoundly impact use of capnography in acute care areas with the goal of improving patient care.
Collapse
Affiliation(s)
| | | | - Paula Schaeffer
- Department of Pediatrics, Yale University School of Medicine
| | - Andrea G Asnes
- Department of Pediatrics, Yale University School of Medicine
| | - Antonio Riera
- Section of Emergency Medicine, Yale University School of Medicine
| |
Collapse
|
298
|
|
299
|
Goto Y, Maeda T, Nakatsu-Goto Y. Decision tree model for predicting long-term outcomes in children with out-of-hospital cardiac arrest: a nationwide, population-based observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R133. [PMID: 24972847 PMCID: PMC4227055 DOI: 10.1186/cc13951] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 06/11/2014] [Indexed: 12/21/2022]
Abstract
Introduction At hospital arrival, early prognostication for children after out-of-hospital cardiac arrest (OHCA) might help clinicians formulate strategies, particularly in the emergency department. In this study, we aimed to develop a simple and generally applicable bedside tool for predicting outcomes in children after cardiac arrest. Methods We analyzed data of 5,379 children who had undergone OHCA. The data were extracted from a prospectively recorded, nationwide, Utstein-style Japanese database. The primary endpoint was survival with favorable neurological outcome (Cerebral Performance Category (CPC) scale categories 1 and 2) at 1 month after OHCA. We developed a decision tree prediction model by using data from a 2-year period (2008 to 2009, n = 3,693), and the data were validated using external data from 2010 (n = 1,686). Results Recursive partitioning analysis for 11 predictors in the development cohort indicated that the best single predictor for CPC 1 and 2 at 1 month was the prehospital return of spontaneous circulation (ROSC). The next predictor for children with prehospital ROSC was an initial shockable rhythm. For children without prehospital ROSC, the next best predictor was a witnessed arrest. Use of a simple decision tree prediction model permitted stratification into four outcome prediction groups: good (prehospital ROSC and initial shockable rhythm), moderately good (prehospital ROSC and initial nonshockable rhythm), poor (prehospital non-ROSC and witnessed arrest) and very poor (prehospital non-ROSC and unwitnessed arrest). By using this model, we identified patient groups ranging from 0.2% to 66.2% for 1-month CPC 1 and 2 probabilities. The validated decision tree prediction model demonstrated a sensitivity of 69.7% (95% confidence interval (CI) = 58.7% to 78.9%), a specificity of 95.2% (95% CI = 94.1% to 96.2%) and an area under the receiver operating characteristic curve of 0.88 (95% CI = 0.87 to 0.90) for predicting 1-month CPC 1 and 2. Conclusions With our decision tree prediction model using three prehospital variables (prehospital ROSC, initial shockable rhythm and witnessed arrest), children can be readily stratified into four groups after OHCA. This simple prediction model for evaluating children after OHCA may provide clinicians with a practical bedside tool for counseling families and making management decisions soon after patient arrival at the hospital.
Collapse
|
300
|
Erker CG, Santamaria M, Moellmann M. Size does matter--age-related weight estimation in "tall n' thin" and "tiny n' thick" children and a new habitus-adapted alternative to the EPLS-formula. Resuscitation 2014; 85:1174-8. [PMID: 24882103 DOI: 10.1016/j.resuscitation.2014.04.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 04/16/2014] [Accepted: 04/18/2014] [Indexed: 11/28/2022]
Abstract
AIM OF THE STUDY Weight in kilograms is a required parameter in the emergency medical care of children. In emergent situations, obtaining an accurate weight is often not possible. In such situations, weight can be estimated by using an age-dependent formula such as the EPLS-formula (age in years+4)×2. As recently recognized for emergency tapes, the habitus of the child has a major influence on weight estimation. In this study, the performance of various age-dependent formulas is to be investigated, with special regard to children demonstrating non-normal growth. METHODS The performance of various formulas for weight estimation in children growing along the 5th, 50th, and 95th percentile is investigated based on a mathematical model compared to the WHO and CDC reference percentiles using ICC and Bland-Altman methods. Additionally, a new formula for children demonstrating non-normal growth is derived by regression analysis and tested: f×age in years+6 with the factor f being 2 for "tall n' thin", 3 for normal and 4 for "tiny n' thick" children. RESULTS All previously published formulas lack precision when applied to children outside the 50th percentile. The new habitus-adapted formula shows a better performance for children growing along the 5th or 95th percentile. CONCLUSIONS The new formula provides enhanced precision in weight estimation and can help in reducing, e.g. drug dosing errors. It should be used for weight estimation in children demonstrating non-normal weight development and in situations when superior methods such as weighing or habitus-adapted emergency tapes are not applicable.
Collapse
Affiliation(s)
- Christian G Erker
- Department of Anesthesiology and Operative Intensive Care Medicine, Section Pediatric Anesthesiology, St. Franziskus-Hospital Muenster, Germany.
| | - Mario Santamaria
- Department of Anesthesiology and Operative Intensive Care Medicine, Section Pediatric Anesthesiology, St. Franziskus-Hospital Muenster, Germany
| | - Michael Moellmann
- Department of Anesthesiology and Operative Intensive Care Medicine, Section Pediatric Anesthesiology, St. Franziskus-Hospital Muenster, Germany
| |
Collapse
|