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Cole ET, Harvey G, Foster G, Thabane L, Parker MJ. Study protocol for a randomised controlled trial comparing the efficiency of two provider-endorsed manual paediatric fluid resuscitation techniques. BMJ Open 2013; 3:bmjopen-2013-002754. [PMID: 23524045 PMCID: PMC3612816 DOI: 10.1136/bmjopen-2013-002754] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Paediatric shock is a life-threatening condition with many possible causes and a global impact. Current resuscitation guidelines require rapid fluid administration as a cornerstone of paediatric shock management. However, little evidence is available to inform clinicians how to most effectively perform rapid fluid administration where this is clinically required, resulting in suboptimal knowledge translation of current resuscitation guidelines into clinical practice. OBJECTIVES This study aims to determine which of the two commonly used techniques for paediatric fluid resuscitation (disconnect-reconnect technique and push-pull technique) yields a higher fluid administration rate in a simulated clinical scenario. Secondary objectives include determination of catheter dislodgement rates, subjective and objective measures of provider fatiguability and descriptive information regarding any technical issues encountered with performance of each method under the study. METHODS AND ANALYSIS This study will utilise a randomised crossover trial design. Participants will include consenting healthcare providers from McMaster Children's Hospital. Each participant will administer 900 ml (60 ml/kg) of normal saline to a simulated 15 kg infant as quickly as possible on two separate occasions using the manual fluid administration techniques under the study. The primary outcome, rate of fluid administration, will be evaluated using a paired two-tailed Student t test. ETHICS AND DISSEMINATION This protocol has been approved by the Hamilton Health Sciences Research Ethics Board. RESULTS These will be published in a peer-reviewed scientific journal and presented at one or more scientific conferences. PROTOCOL REGISTRATION Protocol Registered on ClinicalTrials.gov NCT01774214.
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Affiliation(s)
- Evan T Cole
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Greg Harvey
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Gary Foster
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit/FSORC, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Lehana Thabane
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit/FSORC, St Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Melissa J Parker
- Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Ontario, Canada
- Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
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Maitland K, George EC, Evans JA, Kiguli S, Olupot-Olupot P, Akech SO, Opoka RO, Engoru C, Nyeko R, Mtove G, Reyburn H, Brent B, Nteziyaremye J, Mpoya A, Prevatt N, Dambisya CM, Semakula D, Ddungu A, Okuuny V, Wokulira R, Timbwa M, Otii B, Levin M, Crawley J, Babiker AG, Gibb DM. Exploring mechanisms of excess mortality with early fluid resuscitation: insights from the FEAST trial. BMC Med 2013; 11:68. [PMID: 23496872 PMCID: PMC3599745 DOI: 10.1186/1741-7015-11-68] [Citation(s) in RCA: 178] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 03/14/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Early rapid fluid resuscitation (boluses) in African children with severe febrile illnesses increases the 48-hour mortality by 3.3% compared with controls (no bolus). We explored the effect of boluses on 48-hour all-cause mortality by clinical presentation at enrolment, hemodynamic changes over the first hour, and on different modes of death, according to terminal clinical events. We hypothesize that boluses may cause excess deaths from neurological or respiratory events relating to fluid overload. METHODS Pre-defined presentation syndromes (PS; severe acidosis or severe shock, respiratory, neurological) and predominant terminal clinical events (cardiovascular collapse, respiratory, neurological) were described by randomized arm (bolus versus control) in 3,141 severely ill febrile children with shock enrolled in the Fluid Expansion as Supportive Therapy (FEAST) trial. Landmark analyses were used to compare early mortality in treatment groups, conditional on changes in shock and hypoxia parameters. Competing risks methods were used to estimate cumulative incidence curves and sub-hazard ratios to compare treatment groups in terms of terminal clinical events. RESULTS Of 2,396 out of 3,141 (76%) classifiable participants, 1,647 (69%) had a severe metabolic acidosis or severe shock PS, 625 (26%) had a respiratory PS and 976 (41%) had a neurological PS, either alone or in combination. Mortality was greatest among children fulfilling criteria for all three PS (28% bolus, 21% control) and lowest for lone respiratory (2% bolus, 5% control) or neurological (3% bolus, 0% control) presentations. Excess mortality in bolus arms versus control was apparent for all three PS, including all their component features. By one hour, shock had resolved (responders) more frequently in bolus versus control groups (43% versus 32%, P <0.001), but excess mortality with boluses was evident in responders (relative risk 1.98, 95% confidence interval 0.94 to 4.17, P = 0.06) and 'non-responders' (relative risk 1.67, 95% confidence interval 1.23 to 2.28, P = 0.001), with no evidence of heterogeneity (P = 0.68). The major difference between bolus and control arms was the higher proportion of cardiogenic or shock terminal clinical events in bolus arms (n = 123; 4.6% versus 2.6%, P = 0.008) rather than respiratory (n = 61; 2.2% versus 1.3%, P = 0.09) or neurological (n = 63, 2.1% versus 1.8%, P = 0.6) terminal clinical events. CONCLUSIONS Excess mortality from boluses occurred in all subgroups of children. Contrary to expectation, cardiovascular collapse rather than fluid overload appeared to contribute most to excess deaths with rapid fluid resuscitation. These results should prompt a re-evaluation of evidence on fluid resuscitation for shock and a re-appraisal of the rate, composition and volume of resuscitation fluids. TRIAL REGISTRATION ISRCTN69856593.
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Affiliation(s)
- Kathryn Maitland
- Wellcome Trust Centre for Clinical Tropical Medicine, Department of Paediatrics, Faculty of Medicine, St Marys Campus, Norfolk Place, Imperial College, London W2 1PG, UK
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Elizabeth C George
- Medical Research Council (MRC) Clinical Trials Unit, Aviation House, 125 Kingsway London, WC2B 6NH, UK
| | - Jennifer A Evans
- Department of Paediatrics University Hospital of Wales Heath Park, Cardiff, CF14 4XW, Wales, UK
| | - Sarah Kiguli
- Department of Paediatrics, Mulago Hospital, PO Box 7070, Makerere University, Kampala, Uganda
| | - Peter Olupot-Olupot
- Department of Paediatrics, Mbale Regional Referral Hospital Pallisa Road Zone, PO Box 921, Mbale, Uganda
| | - Samuel O Akech
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Robert O Opoka
- Department of Paediatrics, Mulago Hospital, PO Box 7070, Makerere University, Kampala, Uganda
| | - Charles Engoru
- Department of Paediatrics, Soroti Regional Referral Hospital, PO Box 289, Soroti, Uganda
| | - Richard Nyeko
- Department of Paediatrics, St Mary's Hospital, PO Box 180, Lacor, Uganda
| | - George Mtove
- Department of Paediatrics Joint Malaria Programme, Teule Hospital, PO Box 81, Muheza, Tanzania
| | - Hugh Reyburn
- Department of Paediatrics Joint Malaria Programme, Teule Hospital, PO Box 81, Muheza, Tanzania
- Joint Malaria Programme, PO Box 2228, KCMC, Moshi, Tanzania
| | - Bernadette Brent
- Wellcome Trust Centre for Clinical Tropical Medicine, Department of Paediatrics, Faculty of Medicine, St Marys Campus, Norfolk Place, Imperial College, London W2 1PG, UK
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Julius Nteziyaremye
- Department of Paediatrics, Mbale Regional Referral Hospital Pallisa Road Zone, PO Box 921, Mbale, Uganda
| | - Ayub Mpoya
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Natalie Prevatt
- Wellcome Trust Centre for Clinical Tropical Medicine, Department of Paediatrics, Faculty of Medicine, St Marys Campus, Norfolk Place, Imperial College, London W2 1PG, UK
| | - Cornelius M Dambisya
- Department of Paediatrics, Mbale Regional Referral Hospital Pallisa Road Zone, PO Box 921, Mbale, Uganda
| | - Daniel Semakula
- Department of Paediatrics, Mulago Hospital, PO Box 7070, Makerere University, Kampala, Uganda
| | - Ahmed Ddungu
- Department of Paediatrics, Mulago Hospital, PO Box 7070, Makerere University, Kampala, Uganda
| | - Vicent Okuuny
- Department of Paediatrics, Soroti Regional Referral Hospital, PO Box 289, Soroti, Uganda
| | - Ronald Wokulira
- Department of Paediatrics, Soroti Regional Referral Hospital, PO Box 289, Soroti, Uganda
| | - Molline Timbwa
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Benedict Otii
- Department of Paediatrics, St Mary's Hospital, PO Box 180, Lacor, Uganda
| | - Michael Levin
- Wellcome Trust Centre for Clinical Tropical Medicine, Department of Paediatrics, Faculty of Medicine, St Marys Campus, Norfolk Place, Imperial College, London W2 1PG, UK
| | - Jane Crawley
- Medical Research Council (MRC) Clinical Trials Unit, Aviation House, 125 Kingsway London, WC2B 6NH, UK
| | - Abdel G Babiker
- Medical Research Council (MRC) Clinical Trials Unit, Aviation House, 125 Kingsway London, WC2B 6NH, UK
| | - Diana M Gibb
- Medical Research Council (MRC) Clinical Trials Unit, Aviation House, 125 Kingsway London, WC2B 6NH, UK
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Parker MJ, Manan A. Translating resuscitation guidelines into practice: health care provider attitudes, preferences and beliefs regarding pediatric fluid resuscitation performance. PLoS One 2013; 8:e58282. [PMID: 23554882 PMCID: PMC3595280 DOI: 10.1371/journal.pone.0058282] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 02/01/2013] [Indexed: 11/18/2022] Open
Abstract
Introduction Children who require fluid resuscitation for the treatment of shock present to tertiary and non-tertiary medical settings. While timely fluid therapy improves survival odds, guidelines are poorly translated into clinical practice. The objective of this study was to characterize the attitudes, preferences and beliefs of health care providers working in acute care settings regarding pediatric fluid resuscitation performance. Methods A single-centre survey study was conducted at McMaster Children's Hospital from January to May, 2012. The sampling frame (n = 115) included nursing staff, physician staff and subspecialty trainees working in Pediatric Emergency Medicine (PEM) or Pediatric Critical Care Medicine (PCCM). A self-administered questionnaire was developed and assessed for face validity prior to distribution. Eligible participants were invited at 0, 2, and 4 weeks to complete a web-based version of the survey. A follow-up survey administration phase was conducted to improve the response rate. Results Response rate was 72.2% (83/115), with 83% (68/82) self-identifying as nursing staff and 61% (50/82) as PCCM providers. Resuscitation experience, frequency of shock management, and years in specialty, were similar between PCCM and PEM responders. Physicians and nurses had differing opinions regarding the most effective method to achieve rapid fluid resuscitation in young children presenting in shock (p<0.001). Disagreement also existed regarding the age and size of patients in whom rapid infuser devices, such as the Level-1 Rapid Infuser, should be used (p<0.001). Providers endorsed a number of potential concerns related to the use of rapid infuser devices in children, and only 14% of physicians and 55% of nursing staff felt that they had received adequate training in the use of such devices (p = 0.005). Conclusions There is a lack of consensus among health care providers regarding how pediatric fluid resuscitation guidelines should be operationalized, supporting a need for further work to define best practices.
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Affiliation(s)
- Melissa J Parker
- Department of Pediatrics, McMaster Children's Hospital and McMaster, University, Hamilton, Ontario, Canada.
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Badaki-Makun O, Nadel F, Donoghue A, McBride M, Niles D, Seacrist T, Maltese M, Zhang X, Paridon S, Nadkarni VM. Chest compression quality over time in pediatric resuscitations. Pediatrics 2013; 131:e797-804. [PMID: 23439892 DOI: 10.1542/peds.2012-1892] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Oluwakemi Badaki-Makun
- Emergency Medicine and Trauma Center, Children's National Medical Center, Washington, DC 20010, USA.
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Mittiga MR, Geis GL, Kerrey BT, Rinderknecht AS. The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View. Ann Emerg Med 2013; 61:263-70. [DOI: 10.1016/j.annemergmed.2012.06.021] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 06/11/2012] [Accepted: 06/27/2012] [Indexed: 11/30/2022]
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Abstract
BACKGROUND Ischemia depletes antioxidant reserves and impairs mitochondrial electron transport. Oxygen within blood reperfusing ischemic tissue can form free radicals, worsen oxidative stress, and exacerbate tissue injury (reperfusion injury). One strategy for limiting reperfusion injury is to limit delivery of "luxuriant" oxygen during or after reperfusion. Resuscitation guidelines for children with cardiac arrest recommend early weaning of supplemental oxygen as tolerated. There are currently no studies demonstrating the frequency and outcomes of hyperoxia and hypoxia after pediatric cardiac arrest. OBJECTIVE To determine the frequency and outcomes of hyperoxia and hypoxia in patients following resuscitation from pediatric cardiac arrest admitted to a tertiary care center. DESIGN AND METHODS This is a retrospective observational cohort study. Charts of children resuscitated from cardiac arrest and admitted to our hospital from 2004 to 2008 were reviewed. Partial pressures of oxygen (PaO2) obtained within the first 24 hours following return of spontaneous circulation and mortality at 6 months was recorded. Children who did not survive the initial 48 hours, patients having undergone extracorporeal oxygenation or had congenital heart disease, and those in whom arterial blood gases were not obtained were excluded. RESULTS Seventy-four patients met inclusion criteria. Of these, 38 (51%) had at least one arterial blood gases with a PaO2 > 300 mm Hg and 10 (14%) had a PaO2 < 60 mm Hg in the first 24 hours. Neither hyperoxia nor hypoxia on initial arterial blood gases (p = 0.912 and p = 0.384) nor any arterial blood gases within the first 24 hours after cardiac arrest (p = 0.325 and p = 0.553) was associated with 6-month mortality. CONCLUSIONS Hyperoxia occurs commonly within the first 24 hours of management in children resuscitated from cardiac arrest.
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357
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Lowry AW. Resuscitation and perioperative management of the high-risk single ventricle patient: first-stage palliation. CONGENIT HEART DIS 2013; 7:466-78. [PMID: 22985457 DOI: 10.1111/j.1747-0803.2012.00710.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Infants born with hypoplastic left heart syndrome or other lesions resulting in a single right ventricle face the highest risk of mortality among all forms of congenital heart disease. Before the modern era of surgical palliation, these conditions were universally lethal; recent refinements in surgical technique and perioperative management have translated into dramatic improvements in survival. Nonetheless, these infants remain at a high risk of morbidity and mortality, and an appreciation of single ventricle physiology is fundamental to the care of these high-risk patients. Herein, resuscitation and perioperative management of infants with hypoplastic left heart syndrome are reviewed. Basic neonatal and pediatric life support recommendations are summarized, and perioperative first-stage clinical management strategies are reviewed.
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Affiliation(s)
- Adam W Lowry
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
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358
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Abstract
Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.
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Affiliation(s)
- Fernando Soto
- Pediatric Emergency Medicine Section, University of Puerto Rico School of Medicine, PO Box 29207, San Juan, PR 00929, USA.
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359
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Temperaturregulationsstörungen im Kindesalter. Monatsschr Kinderheilkd 2013. [DOI: 10.1007/s00112-012-2783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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360
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Kim WJ, Kim JJ, Jang JH, Hyun SY, Yang HJ, Lee G. Implementation of Therapeutic Hypothermia after Pediatric Out-of Hospital Cardiac Arrest in One Tertiary Emergency Center. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.1.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Woo Jin Kim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jin Joo Kim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jae Ho Jang
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Youl Hyun
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyuk Jun Yang
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Gun Lee
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
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361
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Girotra S, Spertus JA, Li Y, Berg RA, Nadkarni VM, Chan PS. Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines-Resuscitation. Circ Cardiovasc Qual Outcomes 2012; 6:42-9. [PMID: 23250980 DOI: 10.1161/circoutcomes.112.967968] [Citation(s) in RCA: 250] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite ongoing efforts to improve the quality of pediatric resuscitation, it remains unknown whether survival in children with in-hospital cardiac arrest has improved. METHODS AND RESULTS Between 2000 and 2009, we identified children (<18 years of age) with an in-hospital cardiac arrest at hospitals with >3 years of participation and >5 cases annually within the national Get With The Guidelines-Resuscitation registry. Multivariable logistic regression was used to examine temporal trends in survival to discharge. We also explored whether trends in survival were attributable to improvement in acute resuscitation or postresuscitation care and examined trends in neurological disability among survivors. Among 1031 children at 12 hospitals, the initial cardiac arrest rhythm was asystole and pulseless electrical activity in 874 children (84.8%) and ventricular fibrillation and pulseless ventricular tachycardia in 157 children (15.2%), with an increase in cardiac arrests due to pulseless electrical activity over time (P for trend <0.001). Risk-adjusted rates of survival to discharge increased from 14.3% in 2000 to 43.4% in 2009 (adjusted rate ratio per year, 1.08; 95% confidence interval, 1.01-1.16; P for trend=0.02). Improvement in survival was driven largely by an improvement in acute resuscitation survival (risk-adjusted rates: 42.9% in 2000, 81.2% in 2009; adjusted rate ratio per year: 1.04; 95% confidence interval, 1.01-1.08; P for trend=0.006). Moreover, survival trends were not accompanied by higher rates of neurological disability among survivors over time (unadjusted P for trend=0.32), suggesting an overall increase in the number of survivors without neurological disability over time. CONCLUSIONS Rates of survival to hospital discharge in children with in-hospital cardiac arrests have improved over the past decade without higher rates of neurological disability among survivors.
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Affiliation(s)
- Saket Girotra
- University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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362
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McFadyen JG, Ramaiah R, Bhananker SM. Initial assessment and management of pediatric trauma patients. Int J Crit Illn Inj Sci 2012. [PMID: 23181205 PMCID: PMC3500003 DOI: 10.4103/2229-5151.100888] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Injury is the leading cause of death and disability in children. Each year, almost one in six children in the United States require emergency department (ED) care for the treatment of injuries, and more than 10,000 children die from injuries. Severely injured children need to be transported to a facility that is staffed 24/7 by personnel experienced in the management of children, and that has all the appropriate equipment to diagnose and manage injuries in children. Anatomical, physiological, and emotional differences between adults and children mean that children are not just scaled-down adults. Facilities receiving injured children need to be child and family friendly, in order to minimize the psychological impact of injury on the child and their family/carers. Early recognition and treatment of life-threatening airway obstruction, inadequate breathing, and intra-abdominal and intra-cranial hemorrhage significantly increases survival rate after major trauma. The initial assessment and management of the injured child follows the same ATLS® sequence as adults: primary survey and resuscitation, followed by secondary survey. A well-organized trauma team has a leader who designates roles to team members and facilitates clear, unambiguous communication between team members. The team leader stands where he/she can observe the entire team and monitor the “bigger picture.” Working together as a cohesive team, the members perform the primary survey in just a few minutes. Life-threatening conditions are dealt with as soon as they are identified. Necessary imaging studies are obtained early. Constant reassessment ensures that any deterioration in the child's condition is picked up immediately. The secondary survey identifies other injuries, such as intra-abdominal injuries and long-bone fractures, which can result in significant hemorrhage. The relief of pain is an important part of the treatment of an injured child.
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Affiliation(s)
- J Grant McFadyen
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
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363
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Hemodynamic directed CPR improves short-term survival from asphyxia-associated cardiac arrest. Resuscitation 2012; 84:696-701. [PMID: 23142199 DOI: 10.1016/j.resuscitation.2012.10.023] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 09/25/2012] [Accepted: 10/25/2012] [Indexed: 01/11/2023]
Abstract
AIM Adequate coronary perfusion pressure (CPP) during cardiopulmonary resuscitation (CPR) is essential for establishing return of spontaneous circulation. The objective of this study was to compare short-term survival using a hemodynamic directed resuscitation strategy versus an absolute depth-guided approach in a porcine model of asphyxia-associated cardiac arrest. We hypothesized that a hemodynamic directed approach would improve short-term survival compared to depth-guided care. METHODS After 7 min of asphyxia, followed by induction of ventricular fibrillation, 19 female 3-month old swine (31±0.4 kg) were randomized to receive one of three resuscitation strategies: (1) hemodynamic directed care (CPP-20): chest compressions (CCs) with depth titrated to a target systolic blood pressure of 100 mmHg and titration of vasopressors to maintain CPP>20 mmHg; (2) depth 33 mm (D33): target CC depth of 33 mm with standard American Heart Association (AHA) epinephrine dosing; or (3) depth 51 mm (D51): target CC depth of 51 mm with standard AHA epinephrine dosing. All animals received manual CPR guided by audiovisual feedback for 10 min before first shock. RESULTS 45-Min survival was higher in the CPP-20 group (6/6) compared to D33 (1/7) or D51 (1/6) groups; p=0.002. Coronary perfusion pressures were higher in the CPP-20 group compared to D33 (p=0.011) and D51 (p=0.04), and in survivors compared to non-survivors (p<0.01). Total number of vasopressor doses administered and defibrillation attempts were not different. CONCLUSIONS Hemodynamic directed care targeting CPPs>20 mmHg improves short-term survival in an intensive care unit porcine model of asphyxia-associated cardiac arrest.
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Agrawal A, Singh VK, Varma A, Sharma R. Therapeutic applications of vasopressin in pediatric patients. Indian Pediatr 2012; 49:297-305. [PMID: 22565074 DOI: 10.1007/s13312-012-0046-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT Reports of successful use of vasopressin in various shock states and cardiac arrest has lead to the emergence of vasopressin therapy as a potentially major advancement in the management of critically ill children. OBJECTIVE To provide an overview of physiology of vasopressin, rationale of its use and dose schedule in different disease states with special focus on recent advances in the therapeutic applications of vasopressin. DATA SOURCE MEDLINE search (1966-September 2011) using terms vasopressin, terlipressin, arginine-vasopressin, shock, septic shock, vasodilatory shock, cardiac arrest, and resuscitation for reports on vasopressin/terlipressin use in children and manual review of article bibliographies. Search was restricted to human studies. Randomized controlled trials, cohort studies, evaluation studies, case series, and case reports on vasopressin/terlipressin use in children (preterm neonates to 21 years of age) were included. Outcome measures were analysed using following clinical questions: indication, dose and duration of vasopressin/terlipressin use, main effects especially on systemic blood pressure, catecholamine requirement, urine output, serum lactate, adverse effects, and mortality. RESULTS 51 reports on vasopressin (30 reports) and terlipressin (21 reports) use in pediatric population were identified. A total of 602 patients received vasopressin/terlipressin as vasopressors in various catecholamine-resistant states (septic - 176, post-cardiotomy - 136, other vasodilatory/mixed shock - 199, and cardiac arrest - 101). Commonly reported responses include rapid improvement in systemic blood pressure, decline in concurrent catecholamine requirement, and increase in urine output; despite these effects, the mortality rates remained high. CONCLUSION In view of the limited clinical experience, and paucity of randomized controlled trials evaluating these drugs in pediatric population, currently no definitive recommendations on vasopressin/terlipressin use can be laid down. Nevertheless, available clinical data supports the use of vasopressin in critically ill children as a rescue therapy in refractory shock and cardiac arrest.
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Affiliation(s)
- Amit Agrawal
- Departments of Pediatrics, Chirayu Medical College and Hospital, Bhopal, MP, India.
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366
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Solevåg AL, Madland JM, Gjærum E, Nakstad B. Minute ventilation at different compression to ventilation ratios, different ventilation rates, and continuous chest compressions with asynchronous ventilation in a newborn manikin. Scand J Trauma Resusc Emerg Med 2012; 20:73. [PMID: 23075128 PMCID: PMC3558408 DOI: 10.1186/1757-7241-20-73] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 10/12/2012] [Indexed: 11/10/2022] Open
Abstract
Background In newborn resuscitation the recommended rate of chest compressions should be 90 per minute and 30 ventilations should be delivered each minute, aiming at achieving a total of 120 events per minute. However, this recommendation is based on physiological plausibility and consensus rather than scientific evidence. With focus on minute ventilation (Mv), we aimed to compare today’s standard to alternative chest compression to ventilation (C:V) ratios and different ventilation rates, as well as to continuous chest compressions with asynchronous ventilation. Methods Two investigators performed cardiopulmonary resuscitation on a newborn manikin with a T-piece resuscitator and manual chest compressions. The C:V ratios 3:1, 9:3 and 15:2, as well as continuous chest compressions with asynchronous ventilation (120 compressions and 40 ventilations per minute) were performed in a randomised fashion in series of 10 × 2 minutes. In addition, ventilation only was performed at three different rates (40, 60 and 120 ventilations per minute, respectively). A respiratory function monitor measured inspiration time, tidal volume and ventilation rate. Mv was calculated for the different interventions and the Mann–Whitney test was used for comparisons between groups. Results Median Mv per kg in ml (interquartile range) was significantly lower at the C:V ratios of 9:3 (140 (134–144)) and 15:2 (77 (74–83)) as compared to 3:1 (191(183–199)). With ventilation only, there was a correlation between ventilation rate and Mv despite a negative correlation between ventilation rate and tidal volumes. Continuous chest compressions with asynchronous ventilation gave higher Mv as compared to coordinated compressions and ventilations at a C:V ratio of 3:1. Conclusions In this study, higher C:V ratios than 3:1 compromised ventilation dynamics in a newborn manikin. However, higher ventilation rates, as well as continuous chest compressions with asynchronous ventilation gave higher Mv than coordinated compressions and ventilations with 90 compressions and 30 ventilations per minute.
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Affiliation(s)
- Anne L Solevåg
- The Department of Children and Adolescents, Akershus University Hospital, Lørenskog, Norway.
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367
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Adrenal crisis caused by inhaled fluticasone in an adolescent with cystic fibrosis and advanced hepatopathy: a case report. Case Rep Pulmonol 2012; 2012:913574. [PMID: 23056987 PMCID: PMC3465889 DOI: 10.1155/2012/913574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Accepted: 09/05/2012] [Indexed: 12/23/2022] Open
Abstract
Inhaled corticosteroids are widely accepted in the treatment of cystic fibrosis. Long-term use may cause systemic complications, especially high-dose fluticasone. We report about a young man who presented with encephalopathy after excessive physical activity caused by secondary adrenal insufficiency. He recovered quickly after systemic corticosteroid replacement therapy. This problem is considered to be underdiagnosed in clinical practice.
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368
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Côté JM, Chetaille P. Complications rythmiques de la chirurgie des cardiopathies congénitales. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2012. [DOI: 10.1016/s1878-6480(12)70828-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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369
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Bhalala US, Bonafide CP, Coletti CM, Rathmanner PE, Nadkarni VM, Berg RA, Witzke AK, Kasprzak MS, Zubrow MT. Antecedent bradycardia and in-hospital cardiopulmonary arrest mortality in telemetry-monitored patients outside the ICU. Resuscitation 2012; 83:1106-10. [DOI: 10.1016/j.resuscitation.2012.03.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 03/14/2012] [Accepted: 03/19/2012] [Indexed: 10/28/2022]
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370
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Decaen A, Aziz K. Stayin' alive: The 2010 Heart and Stroke Foundation of Canada/American Heart Association resuscitation guidelines for newborns and older children. Paediatr Child Health 2012; 16:267-8. [PMID: 22547940 DOI: 10.1093/pch/16.5.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2011] [Indexed: 11/13/2022] Open
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371
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Escudero C, Carr R, Sanatani S. The Medical Management of Pediatric Arrhythmias. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:455-72. [PMID: 22907424 DOI: 10.1007/s11936-012-0194-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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372
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Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review of the literature. J Pediatr Nurs 2012; 27:416-20. [PMID: 22579781 DOI: 10.1016/j.pedn.2012.04.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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373
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Horeczko T, Enriquez B, McGrath NE, Gausche-Hill M, Lewis RJ. The Pediatric Assessment Triangle: accuracy of its application by nurses in the triage of children. J Emerg Nurs 2012; 39:182-9. [PMID: 22831826 DOI: 10.1016/j.jen.2011.12.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 11/16/2011] [Accepted: 12/28/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Pediatric Assessment Triangle (PAT) is a rapid evaluation tool that establishes a child's clinical status and his or her category of illness to direct initial management priorities. Recently the PAT has been incorporated widely into the pediatric resuscitation curriculum. Although intuitive, its performance characteristics have yet to be quantified. The purpose of this research is to determine quantitatively its accuracy, reliability, and validity as applied by nurses at triage. METHODS In this prospective observational study, triage nurses performed the PAT on all patients presenting to the pediatric emergency department of an urban teaching hospital. Researchers performed blinded chart review using the physician's initial assessment and final diagnosis as the criterion standard for comparison. RESULTS A total of 528 children were included in the analysis. Likelihood ratios (LRs) were found for instability and category of pathophysiology using the PAT. Children deemed stable by initial PAT were almost 10 times more likely to be stable on further assessment (LR 0.12, 95% confidence interval [CI] 0.06-0.25). The PAT further specified categories of pathophysiology: respiratory distress (LR+ 4, 95% CI 3.1-4.8), respiratory failure (LR+ 12, 95% CI 4.0-37), shock (LR+ 4.2, 95% CI 3.1-5.6), central nervous system/metabolic disorder (LR+ 7, 95% CI 4.3-11), and cardiopulmonary failure (LR+ 49, 95% CI 20-120). DISCUSSION The structured assessment of the initial PAT, as performed by nurses in triage, readily and reliably identifies high-acuity pediatric patients and their category of pathophysiology. The PAT is highly predictive of the child's clinical status on further evaluation.
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Affiliation(s)
- Timothy Horeczko
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, CA 90509, USA.
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374
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Affiliation(s)
- Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, The University of Pennsylvania School of Medicine, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104, USA.
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375
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Hemme WJ. A Review of Epinephrine Administration in Pediatric Anaphylaxis. J Emerg Nurs 2012; 38:392-7. [DOI: 10.1016/j.jen.2011.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 09/21/2011] [Accepted: 12/14/2011] [Indexed: 10/28/2022]
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376
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Ferguson LP, Durward A, Tibby SM. Relationship between arterial partial oxygen pressure after resuscitation from cardiac arrest and mortality in children. Circulation 2012; 126:335-42. [PMID: 22723307 DOI: 10.1161/circulationaha.111.085100] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Observational studies in adults have shown a worse outcome associated with hyperoxia after resuscitation from cardiac arrest. Extrapolating from adult data, current pediatric resuscitation guidelines recommend avoiding hyperoxia. We investigated the relationship between arterial partial oxygen pressure and survival in patients admitted to the pediatric intensive care unit (PICU) after cardiac arrest. METHODS AND RESULTS We conducted a retrospective cohort study using the Pediatric Intensive Care Audit Network (PICANet) database between 2003 and 2010 (n=122,521). Patients aged <16 years with documented cardiac arrest preceding PICU admission and arterial blood gas analysis taken within 1 hour of PICU admission were included. The primary outcome measure was death within the PICU. The relationship between postarrest oxygen status and outcome was modeled with logistic regression, with nonlinearities explored via multivariable fractional polynomials. Covariates included age, sex, ethnicity, congenital heart disease, out-of-hospital arrest, year, Pediatric Index of Mortality-2 (PIM2) mortality risk, and organ supportive therapies. Of 1875 patients, 735 (39%) died in PICU. Based on the first arterial gas, 207 patients (11%) had hyperoxia (Pa(O)(2) ≥300 mm Hg) and 448 (24%) had hypoxia (Pa(O)(2) <60 mm Hg). We found a significant nonlinear relationship between Pa(O)(2) and PICU mortality. After covariate adjustment, risk of death increased sharply with increasing hypoxia (odds ratio, 1.92; 95% confidence interval, 1.80-2.21 at Pa(O)(2) of 23 mm Hg). There was also an association with increasing hyperoxia, although not as dramatic as that for hypoxia (odds ratio, 1.25; 95% confidence interval, 1.17-1.37 at 600 mm Hg). We observed an increasing mortality risk with advancing age, which was more pronounced in the presence of congenital heart disease. CONCLUSIONS Both severe hypoxia and, to a lesser extent, hyperoxia are associated with an increased risk of death after PICU admission after cardiac arrest.
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Affiliation(s)
- Lee P Ferguson
- Pediatric Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom.
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377
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Poor KM, Ducklow TB. Benefit of BP Measurement in Pediatric ED Patients. ISRN NURSING 2012; 2012:627354. [PMID: 22778992 PMCID: PMC3385663 DOI: 10.5402/2012/627354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 05/02/2012] [Indexed: 11/30/2022]
Abstract
Introduction. Obtaining blood pressures in pediatric emergency department patients is the standard of care; however, there is little evidence to support its utility. This prospective study assesses the benefit of BP acquisition in patients ≤5 years. Methods. Data were collected by the ED triage nurses on 649 patients in two community hospital EDs. Relationships between abnormal blood pressures and the patients' age, acuity, and calm versus not-calm emotional state were analyzed. Results. There were significant differences in the rate of elevated BPs in the calm and not-calm groups of patients. Overall, one- and two-year-old patients were more likely to have elevated BPs than those in other age groups. Very few patients in the sample had hypotension (1%). There was no relationship between Emergency Severity Index (ESI) acuity level and an abnormal BP. Nineteen percent of calm patients had elevated BPs, with 3.6% of patients in the stage two class of hypertension. Conclusions. There is limited benefit in obtaining BPs in children age of five or less regardless of whether the child is calm or not in ESI acuity levels 3 and 4.
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Affiliation(s)
- Karen M. Poor
- ED/ICU/Telemetry, HealthEast Woodwinds Health Campus, Woodbury, MN 55125, USA
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378
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Brainard BM, Boller M, Fletcher DJ. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 5: Monitoring. J Vet Emerg Crit Care (San Antonio) 2012; 22 Suppl 1:S65-84. [DOI: 10.1111/j.1476-4431.2012.00751.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Benjamin M. Brainard
- Department of Small Animal Medicine and Surgery; College of Veterinary Medicine; University of Georgia; Athens; GA; 30602-7371
| | - Manuel Boller
- Department of Clinical Studies, School of Veterinary Medicine, and the Department of Emergency Medicine; School of Medicine, Center for Resuscitation Science University of Pennsylvania; Philadelphia; PA; 19104
| | - Daniel J. Fletcher
- College of Veterinary Medicine; Cornell University; Ithaca; NY; 14853-6401
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379
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Langhan ML, Auerbach M, Smith AN, Chen L. Improving detection by pediatric residents of endotracheal tube dislodgement with capnography: a randomized controlled trial. J Pediatr 2012; 160:1009-14.e1. [PMID: 22244462 DOI: 10.1016/j.jpeds.2011.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 11/02/2011] [Accepted: 12/09/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The authors sought to determine if capnography could improve time to correction of a simulated endotracheal tube (ETT) dislodgement by pediatric residents. STUDY DESIGN Pediatric residents attended a didactic session that included interpretation of capnography. A randomized controlled study was then performed using patient simulators. Residents were randomized to standard monitoring (control group) or standard monitoring plus capnography (intervention group). The primary outcome was time to correction of ETT dislodgement. Correction of dislodgement prior to decline in pulse oximetry was our secondary outcome. RESULTS Twenty-seven subjects completed the simulation. Subjects in the intervention group corrected the ETT dislodgement faster than those in the control group (2.38 minutes vs 3.92 minutes, P = .02). There were no differences in time to correction based on postgraduate year, clinical experiences, or comfort with capnography. Two subjects corrected the dislodgement prior to changes in pulse oximetry, both from the intervention group. Fifty-nine percent of subjects had seen capnography used in the past and 82% felt very or somewhat comfortable with capnography. CONCLUSION Capnography decreased time to correction of ETT dislodgement by pediatric residents. Capnography should be considered as an essential monitoring device for intubated patients to enhance patient safety.
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Affiliation(s)
- Melissa L Langhan
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
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380
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Vasopressin rescue for in-pediatric intensive care unit cardiopulmonary arrest refractory to initial epinephrine dosing: a prospective feasibility pilot trial. Pediatr Crit Care Med 2012; 13:265-72. [PMID: 21926666 DOI: 10.1097/pcc.0b013e31822f1569] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the feasibility of a large, randomized controlled trial of combination epinephrine-arginine vasopressin for in-pediatric intensive care unit cardiopulmonary arrest refractory to initial epinephrine dosing. DESIGN Prospective, pilot, matched controlled clinical trial using exception from informed consent. SETTING Pediatric intensive care unit in a university-affiliated tertiary care children's hospital. PATIENTS All patients <18 yrs of age admitted to the pediatric intensive care unit with cardiopulmonary arrest requiring chest compressions and epinephrine (0.01 mg/kg) were eligible. INTERVENTIONS Patients who remained in cardiopulmonary arrest despite an initial dose of epinephrine received arginine vasopressin (0.8 U/kg) rescue as the second vasopressor, followed by additional epinephrine if needed. MEASUREMENTS AND MAIN RESULTS Outcome variables included return of spontaneous circulation (≥20 min), survival at 24 hrs, survival to hospital discharge, and neurologic status at discharge. Favorable neurologic status was defined as Pediatric Cerebral Performance Categories 1, 2, and 3, or no change from admission. Data were compared to a retrospective, matched cohort of patients who experienced cardiopulmonary arrest requiring ≥ two doses of vasopressor, and did not receive arginine vasopressin (n = 20). Of 2,654 patients admitted to the pediatric intensive care unit, 29 (1.1%) had refractory cardiopulmonary arrest: five patients were excluded, 14 missed for inclusion, and ten were enrolled. There was increased 24-hr survival (80% vs. 30%, odds ratio 9.33, 95% confidence interval 1.51-57.65) in arginine vasopressin patients. There was no significant difference in return of spontaneous circulation, survival to hospital discharge, or favorable neurologic status at discharge. CONCLUSIONS These pilot data provide support for a larger randomized controlled trial of arginine vasopressin therapy during cardiopulmonary resuscitation for in-hospital pediatric cardiac arrest.
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381
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Abe T, Nagata T, Hasegawa M, Hagihara A. Life support techniques related to survival after out-of-hospital cardiac arrest in infants. Resuscitation 2012; 83:612-8. [DOI: 10.1016/j.resuscitation.2012.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 12/20/2011] [Accepted: 01/17/2012] [Indexed: 10/14/2022]
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382
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Tampo A, Suzuki A, Sako S, Kunisawa T, Iwasaki H, Fujita S. A comparison of the Pentax Airway Scope™ with the Airtraq™ in an infant manikin. Anaesthesia 2012; 67:881-4. [PMID: 22506698 DOI: 10.1111/j.1365-2044.2012.07153.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We compared the Pentax Airway Scope(TM) with the Airtraq(TM) optical laryngoscope in an infant manikin. Twenty-three anaesthetists randomly performed tracheal intubation: at rest, (a) with the Airway Scope and (b) with the Airtraq; and during chest compressions, (c) with the Airway Scope and (d) with the Airtraq. The success rate, modified Cormack and Lehane classification for glottic view, time taken to view the glottis, and time to place the tracheal tube were recorded. There was no difference in intubation success rate or quality of glottic view between the two devices. The median (IQR [range]) time taken to obtain a view of the glottis was 4.5 (3.7-6.4 [1.8-14.0]) s using the Airway Scope compared with 7.1 (5.5-9.6 [3.3-12.0]) s using the Airtraq (p = 0.001), and to successful placement of the tracheal tube was 8.3 (6.8-9.4 [3.7-20.7]) s using the Airway Scope compared with 11.2 (10.4-13.8 [4.9-23.7]) s using the Airtraq (p = 0.001). During chest compressions, the median (IQR [range]) time taken to view the glottis was 5.1 (4.0-7.2 [2.0-12.4]) s using the Airway Scope compared with 7.5 (5.0-13.2 [4.2-26.4]) s using the Airtraq (p = 0.006), and to successful placement of the tracheal tube was 9.5 (6.6-13.7 [4.5-16.2]) s using the Airway Scope compared with 11.7 (9.1-18.1 [6.2-37.4]) s using the Airtraq (p = 0.022). We conclude that both devices provided good quality views of the glottis and successful tracheal intubation in an infant manikin both at rest and during external chest compressions. Use of the Airway Scope resulted in a shorter time to view the glottis and perform successful tracheal intubation compared with the Airtraq.
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Affiliation(s)
- A Tampo
- Department of Emergency Medicine, Asahikawa Medical University Hospital, Asahikawa, Japan.
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383
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Stricker PA, Lin EE, Fiadjoe JE, Sussman EM, Jobes DR. Absence of tachycardia during hypotension in children undergoing craniofacial reconstruction surgery. Anesth Analg 2012; 115:139-46. [PMID: 22504212 DOI: 10.1213/ane.0b013e318253708c] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Tachycardia is a baroreceptor-mediated response to hypotension. Heart rate (HR) behavior in the setting of hypotension in anesthetized children is not well characterized. We conducted this study to assess the relationship between HR and hypotension in a population of anesthetized children experiencing massive blood loss. Our primary hypothesis was that HR would be increased with the onset of hypotension associated with hypovolemia in comparison with time points without hypotension. METHODS We performed a query of our prospective craniofacial perioperative registry for children younger than 24 months who underwent cranial vault reconstruction surgery. Demographic and perioperative data were extracted, and the intraoperative blood loss was calculated. Vital signs were extracted from our computerized anesthesia record and analyzed. Hypotension was defined as a mean arterial blood pressure <40 mm Hg for at least 3 computerized anesthesia record entries (captured every 15 seconds). The preoperative HR, the average HR over the entire intraoperative period, the HR at the onset of hypotension, and the HR 5 minutes before and 5 minutes after the hypotensive episode were compared. RESULTS The registry query yielded data from 57 procedures. There were 29 episodes of hypotension occurring in 10 subjects. There was no significant difference in HR at the onset of hypotension (when mean arterial blood pressure decreased below 40 mm Hg) in comparison with the preoperative HR, the average intraoperative HR, or in comparison with 5 minutes before and 5 minutes after the episode of hypotension. CONCLUSIONS In this study of anesthetized children younger than 24 months undergoing surgery with massive blood loss, hypotension was not associated with an increased HR. HR does not appear to be a useful indicator of hypovolemia in this population.
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Affiliation(s)
- Paul A Stricker
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA.
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384
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Sunde K, Steen PA. The Use of Vasopressor Agents During Cardiopulmonary Resuscitation. Crit Care Clin 2012; 28:189-98. [PMID: 22433482 DOI: 10.1016/j.ccc.2011.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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385
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Heyming T, Bosson N, Kurobe A, Kaji AH, Gausche-Hill M. Accuracy of Paramedic Broselow Tape Use in the Prehospital Setting. PREHOSP EMERG CARE 2012; 16:374-80. [DOI: 10.3109/10903127.2012.664247] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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386
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387
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Abstract
Intraosseous cannulation is an increasingly common means of achieving vascular access for the administration of fluids and medications during the emergent resuscitation of both paediatric and adult patients. Improved tools and techniques for intraosseous vascular access have recently been developed, enabling the healthcare provider to choose from a wide range of devices and insertion sites. Despite its increasing popularity within the adult population, and decades of use in the paediatric population, questions remain regarding the safety and efficacy of intraosseous infusion. Although various potential complications of intraosseous cannulation have been theorized, few serious complications have been reported. This article aims to provide a review of the current literature on intraosseous vascular access, including discussion on the various intraosseous devices currently available in the market, the advantages and disadvantages of intraosseous access compared to conventional vascular access methods, complications of intraosseous cannulation and current recommendations on the use of this approach.
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Affiliation(s)
- James H Paxton
- Department of Emergency Medicine, Detroit Medical Center, Detroit, MI, USA
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388
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Hoskins SL, do Nascimento P, Lima RM, Espana-Tenorio JM, Kramer GC. Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary resuscitation. Resuscitation 2012; 83:107-12. [PMID: 21871857 DOI: 10.1016/j.resuscitation.2011.07.041] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 07/20/2011] [Accepted: 07/26/2011] [Indexed: 01/15/2023]
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389
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Abstract
Therapeutic hypothermia (TH) is the intentional reduction of core body temperature to 32°C to 35°C, and is increasingly applied by intensivists for a variety of acute neurological injuries to achieve neuroprotection and reduction of elevated intracranial pressure. TH improves outcomes in comatose patients after a cardiac arrest with a shockable rhythm, but other off-label applications exist and are likely to increase in the future. This comprehensive review summarizes the physiology and cellular mechanism of action of TH, as well as different means of TH induction and maintenance with potential side effects. Indications of TH are critically reviewed by disease entity, as reported in the most recent literature, and evidence-based recommendations are provided.
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Affiliation(s)
- Lucia Rivera-Lara
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
| | - Jiaying Zhang
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
- Departments of Neurology (Division of Neurocritical Care), Anesthesia/Critical Care and Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01655 USA
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390
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Potential Therapeutic Targets for Cerebral Resuscitation After Global Ischemia. Transl Stroke Res 2012. [DOI: 10.1007/978-1-4419-9530-8_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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391
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Looking into the crystal ball: can we predict prognosis in children treated with therapeutic hypothermia after cardiac arrest? Pediatr Crit Care Med 2012; 13:97-8. [PMID: 22222645 DOI: 10.1097/pcc.0b013e318223125a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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392
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Pediatric Advanced Life Support Update for the Emergency Physician: Review of 2010 Guideline Changes. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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393
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Extracorporeal cardiopulmonary resuscitation for post-operative cardiac arrest: indications, techniques, controversies, and early results--what is known (and unknown). Cardiol Young 2011; 21 Suppl 2:109-17. [PMID: 22152537 DOI: 10.1017/s1047951111001685] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation may be defined as the use of extracorporeal membrane oxygenation for the support of patients who do not respond to conventional cardiopulmonary resuscitation. Data from national and international paediatric databases indicate that the use of extracorporeal cardiopulmonary resuscitation is increasing. Guidelines from the American Heart Association suggest that any patient with refractory cardiopulmonary resuscitation and potentially reversible causes of cardiac arrest is a candidate for extracorporeal cardiopulmonary resuscitation. One possible framework for selection of patients for extracorporeal cardiopulmonary resuscitation includes dividing patients on the basis of favourable or unfavourable characteristics. Favourable characteristics include cardiac disease, witnessed event in the intensive care unit, ability to deliver effective cardiopulmonary resuscitation, active patient monitoring present, favourable arterial blood gases, and early institution of extracorporeal membrane oxygenation. Unfavourable characteristics potentially include non-cardiac disease, an unwitnessed cardiac arrest, ineffective cardiopulmonary resuscitation, and severely acidotic arterial blood gases. Considering the significant resources and cost involved in the use of extracorporeal cardiopulmonary resuscitation, its use needs to be critically examined to improve outcomes, assess neurological recovery and quality of life, and help identify populations and other factors that may help guide in the selection of patients for successful extracorporeal cardiopulmonary resuscitation.
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394
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Bustos R. [Therapeutic hypothermia after pediatric cardiac arrest]. An Pediatr (Barc) 2011; 76:98-102. [PMID: 22078864 DOI: 10.1016/j.anpedi.2011.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 07/02/2011] [Accepted: 07/20/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Therapeutic hypothermia (TH) improves neurological outcome in adults after ventricular fibrillation cardiac arrest and in neonates with hypoxic ischemic encephalopathy. The effect of TH in children is under investigation. OBJECTIVES To assess the feasibility, efficacy and safety of a pilot program of TH in pediatric cardiac arrest. MATERIAL AND METHODS Prospective study in a pediatric intensive care unit. An external cooling method with a servo system was used on all patients according to an established protocol. Values expressed as median (IQ range). RESULTS Six patients were included, of whom 5 had an out of hospital cardiac arrest. The mean age was 33 months (16-120) and Glasgow coma scale 6 (4-7). The T° prior to the induction of TH was 39.2° C (39.1-39.4). The median T° used was 34.0° C (33.5-34.8° C), which was reached in 4h. (3-7) after the start and maintained for 48h. (45-54). The rewarming was carried out over a period of 14h. (12-16). Hypokalemia was the most common adverse event found. Five patients survived to hospital discharge with a Glasgow Coma Scale of 13 (11-14). At 6 months follow up the Pediatric Cerebral Performance Category score was ≤ 2 in three patients. CONCLUSION In this pilot study, the use of mild therapeutic hypothermia with a protocol that included rapid sequence induction with an external surface cooling technique was feasible, effective and safe in children with cardiac arrest.
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Affiliation(s)
- R Bustos
- Unidad de Cuidados Intensivos Pediátricos, Hospital Guillermo Grant Benavente, Concepción, Chile.
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395
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DeBoer S, Seaver M. Knowledge Assessment and Preparation for the Certified Pediatric Emergency Nurse Examination. J Emerg Nurs 2011. [DOI: 10.1016/j.jen.2011.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chéron G, Saint-Blanquat L, Nouyrigat V, Bocquet N. Prise en charge de l’arrêt cardiaque du nourrisson et de l’enfant. ANNALES FRANCAISES DE MEDECINE D URGENCE 2011. [DOI: 10.1007/s13341-011-0121-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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397
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Niebauer JM, White ML, Zinkan JL, Youngblood AQ, Tofil NM. Hyperventilation in pediatric resuscitation: performance in simulated pediatric medical emergencies. Pediatrics 2011; 128:e1195-200. [PMID: 21969287 DOI: 10.1542/peds.2010-3696] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the hypothesis that pediatric resuscitation providers hyperventilate patients via bag-valve-mask (BVM) ventilation during performance of cardiopulmonary resuscitation (CPR), quantify the degree of excessive ventilation provided, and determine if this tendency varies according to provider type. METHODS A retrospective, observational study was conducted of 72 unannounced, monthly simulated pediatric medical emergencies ("mock codes") in a tertiary care, academic pediatric hospital. Responders were code team members, including pediatric residents and interns (MDs), respiratory therapists (RTs), and nurses (RNs). All sessions were video-recorded and reviewed for the rate of BVM ventilation, rate of chest compressions, and the team members performing these tasks. The type of emergency, location of the code, and training level of the team leader were also recorded. RESULTS Hyperventilation was present in every mock code reviewed. The mean rate of BVM ventilation for all providers in all scenarios was 40.6 ± 11.8 breaths per minute (BPM). The mean ventilation rates for RNs, RTs, and MDs were 40.8 ± 14.7, 39.9 ± 11.7, and 40.5 ± 10.3 BPM, respectively, and did not differ among providers (P = .94). All rates were significantly higher than the recommended rate of 8 to 20 BPM (per Pediatric Advanced Life Support guidelines, varies with patient age) (P < .001). The mean ventilation rate in cases of isolated respiratory arrest was 44.0 ± 13.9 BPM and was not different from the mean BVM ventilation rate in cases of cardiopulmonary arrest (38.9 ± 14.4 BPM; P = .689). CONCLUSIONS Hyperventilation occurred in simulated pediatric resuscitation and did not vary according to provider type. Future educational interventions should focus on avoidance of excessive ventilation.
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Affiliation(s)
- Julia M Niebauer
- Division of Critical Care, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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Tegtmeyer K, Conway EE, Upperman JS, Kissoon N. Education in a pediatric emergency mass critical care setting. Pediatr Crit Care Med 2011; 12:S135-40. [PMID: 22067922 DOI: 10.1097/pcc.0b013e318234a764] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION An emergency mass critical care event puts significant strains on all healthcare resources, including equipment, supplies, and manpower; it leads to extraordinary stresses on healthcare providers, many of whom will be expected to deliver care outside of their usual scope of practice. Education and educational resources will be critically important for training providers and diminishing the stress, anxiety, and chaos of delivering pediatric emergency mass critical care. This article suggests educational tools, as well as potential resources, that need to be developed to cope with a pediatric emergency mass critical care event. METHODS In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subgroups by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. TASK FORCE RECOMMENDATIONS Identifying educational needs to prepare for a pediatric emergency mass critical care event is essential for all healthcare organizations. Educational strategies and tactics should be developed at multiple levels for a comprehensive approach to preparing for pediatric emergency mass critical care.
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Affiliation(s)
- Ken Tegtmeyer
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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