European Resuscitation Council Guidelines 2021: Paediatric Life Support

Impact of a Two-Person Mask Ventilation Technique during Neonatal Resuscitation: A Simulation-Based Randomized Controlled Trial

OBJECTIVE

To assess whether the two-person ventilation technique during simulated neonatal resuscitation enables higher ventilation quality compared with the one-person technique, as measured by expiratory tidal volume (eVT), mask leak, positive inspiratory pressure, respiratory rate, and minute ventilation.

STUDY DESIGN

We conducted a randomized, cross-over simulation trial including 74 neonatal care providers at the Neonatal Simulation Center, Children's Hospital of Philadelphia. Participants performed bag-mask ventilation using one-person and two-person techniques in a randomized order. Ventilation parameters were recorded using a respiratory function monitor. Visual attention was analyzed using eye-tracking technology . The primary outcome was the time to achieve effective ventilation defined by eVT between 4-8ml/kg and mask leak ≤30% for 10 consecutive seconds.

RESULTS

No participant achieved the primary ventilation target in either technique. The two-person technique showed higher eVT (9.7 mL/kg vs. 8.4 mL/kg, absolute difference -1.3mL/kg, 95% confidence interval (CI) [-2.4, -0.1], p = 0.032) and a significant reduction in mask leak (48.9% vs. 62.9%, absolute difference of 14.0%, 95% CI [6.4, 22.0], p < 0.001). Eye-tracking indicated differing visual attention patterns between techniques, with the two-person technique focusing more on the mask and bag (dwell time: 25% one-person vs. 34% two-person, p=0.13).

CONCLUSIONS

The two-person ventilation technique was associated with increased eVT and decreased mask leak during simulated neonatal resuscitation. Further research is needed to evaluate the impact of different ventilation devices and techniques in clinical settings.

Evaluating Novel Chest Compression Technique in Infant CPR: Enhancing Efficacy and Reducing Rescuer Fatigue in Single-Rescuer Scenarios

Background/Objectives: Effective infant cardiopulmonary resuscitation (CPR) relies on high-quality chest compressions, yet the optimal technique for single-rescuer scenarios remains debated. Although widely used, the two-finger technique (TFT) is associated with an inadequate compression depth and increased rescuer fatigue. While the two-thumb encircling hands technique (TTHT) provides a superior compression depth, its application in single-rescuer scenarios is impractical. This study evaluates a novel technique (nT) as a potential alternative, aiming to optimize both compression efficacy and rescuer endurance. Methods: This randomized crossover study assessed the efficacy of the TFT, TTHT, and nT in a simulated infant CPR setting. Medical students trained in newborn and infant resuscitation performed all three techniques in a controlled environment using a high-fidelity neonatal simulator. We objectively measured and compared key CPR performance metrics, rescuer fatigue, and hand pain among the techniques. Results: The nT and TTHT outperformed the TFT in compression depth, rescuer endurance, and overall CPR quality. The nT achieved the highest adequate compression rate (92.4% vs. 78.6% for TTHT and 65.2% for TFT) while minimizing fatigue (RPE: 3.1 vs. 4.5 for TTHT and 6.2 for TFT) and hand pain (NRS: 1.8 vs. 3.9 for TTHT and 5.4 for TFT). TTHT produced the deepest compressions (mean: 44.2 mm vs. 42.9 mm for nT and 38.6 mm for TFT, p < 0.001). Rescuer anthropometric factors (sex, weight, and height) affected all techniques similarly, suggesting no inherent advantage based on body characteristics. Conclusions: Both the nT and TTHT outperformed the TFT, with the nT demonstrating superior rescuer endurance while maintaining high-quality compressions. Given its ergonomic benefits and effectiveness, the nT emerges as a promising alternative for single-rescuer infant CPR and warrants consideration for future resuscitation guidelines.

Automated external defibrillator: Rhythm analysis and defibrillation on paediatric out-of-hospital cardiac arrest

Objective

This study aims to quantify the reliability of automated external defibrillators (AED) in paediatric out-of-hospital cardiac arrests (pOHCA) by evaluating the defibrillation and the shock advisory system efficacy. Furthermore, the relationship between the initial energy dose and patient outcomes is analysed.

Methods

We studied data from all pOHCA cases (age < 18 years) treated by the Paris Fire Brigade between January 2010 and December 2018, limited to those with available AED signals. The efficacy of shocks is the primary outcome. The secondary outcomes are the shock advisory system performance, pre-hospital return of a spontaneous circulation (ROSC), survival and energy dose. Energy dose, weight and age are compared using a Wilcoxon test according to the outcome's values.

Results

A total of 1,990 electrocardiogram strips extracted from 349 pOHCA cases were included in the study. Shock advisory system had a sensitivity of 89.4% and a specificity of 99.8% for the detection of shockable rhythms. Shock efficacy observed for all patients who received a shock was 83.1% and first shock efficacy for patients in initial ventricular fibrillation was 96%. Patients who received a shock had a pre-hospital ROSC rate of 74.3%, a survival rate at hospital admission of 71.4% and 34.3% at hospital discharge.

Conclusion

This study shows that AED detect shockable rhythm with a good sensitivity and specificity and that shocks are associated with a very high rates of termination of shockable rhythms in pOHCA.

Time delay and risk of toxicity of intraosseous anaesthesia use for awake intraosseous access in children

INTRODUCTION

Intraosseous access (IO) is a crucial, life-saving alternative vascular access in paediatric emergency medicine. In awake paediatric patients, the pain of drilling and flushing the marrow cavity are barriers to the use of the IO method or prompt the use of an intraosseous anaesthetic agent, which introduces the risk of dosing errors and drug toxicity. This study aims to identify the frequency of use of anaesthetic agents and analyse the time delay caused by their use.

METHODS

Prospective surveillance study analysing all patients, aged > 28 days to 18 years, who received one or more IO attempt(s) in and out of the hospital setting in Germany from 1 July 2017 to 30 June 2019 via the reporting mechanism of the German Paediatric Surveillance Unit (GPSU).

RESULTS

Our analysis identified 74 patients who received an IO attempt while awake. All patients were younger than 6 years old. Almost every third child (31.6%) was awake during IO use. In 18.9% of all awake patients, an intraosseous anaesthetic was used before the IO was drilled or the marrow cavity was flushed, introducing a significant time delay of approximately 3 min (p = 0.001) compared to IO attempts without intraosseous anaesthesia.

CONCLUSIONS

Intraosseous anaesthesia prolongs the establishment of working vascular access in an emergency and introduces the risk of drug toxicity. To prevent adverse events, particular emphasis must be placed on placement without intraosseous anaesthesia, and alternative pain management (intranasal) must be considered if necessary. Training courses and guidelines should reflect the advised current practice.

Association between early radiographic chest findings and clinical outcomes in pediatric drowning: a retrospective study in a tertiary Italian hospital

Pediatric drowning incidents, both fatal and non-fatal, represent a significant challenge in emergency medicine, particularly for children under 14 years of age. Drowning is a leading cause of unintentional injury-related deaths, with children aged one to four years being especially vulnerable. Accurate and timely assessment, particularly through chest imaging, such as chest radiography (CXR) and lung point-of-care ultrasound (LUS), is crucial for evaluating pulmonary complications and guiding treatment decisions. This retrospective study analyzed 64 pediatric drowning cases in Istituto Giannina Gaslini, Italy, from 2012 to 2023. For all patients, demographic data, vital parameters, blood tests upon PED admission and at 24 h, need for intensive care unit admission, length of stay, therapies administered, ventilatory support in the PED and in the hospital ward, and mortality were recorded. The patients were subsequently divided into two groups based on the chest X-ray result. The results indicated that pathological CXR findings upon admission were associated with a higher likelihood of hospital admission, prolonged hospital stay, and more severe clinical outcomes, including the need for oxygen supplementation and antibiotic therapy. Patients with abnormal CXR findings also exhibited lower oxygen saturation, Glasgow Coma Scale scores, and body temperature upon admission, reflecting a more significant physiological compromise, and higher RCP values at 24 h.

CONCLUSION

Although the majority of non-fatal drowning patients recovered without lasting neurological deficits, the findings suggest that CXR plays a critical role in early management, assisting in the identification of those at greater risk for complications.

WHAT IS KNOWN

• Fatal and non-fatal pediatric drowning incidents may represent a critical issue in pediatric emergency medicine, requiring prompt assessment and accurate management upon admission, even if standardized protocols are lacking.

WHAT IS NEW

• Chest imaging in the initial assessment of pediatric drowning cases may serve as a fundamental tool to support early clinical decision-making, particularly when integrated with other key parameters such as neurological status, vital signs, and blood exams.

Confirmation of successful supraglottic airway device placement in neonates using a respiratory function monitor

BACKGROUND

This study investigated the use of a respiratory function monitor (RFM) to guide the placement of a supraglottic airway device (SAD) in neonates during intensive care interventions. We hypothesized that using a RFM would decrease the number of attempts needed for a successful placement.

METHODS

This single-center pilot study was carried out at a tertiary NICU at the Medical University of Vienna. Patients were ventilated using a SAD during neurosurgical or endoscopic interventions. A RFM was either hidden (but recording) or visible to providers during SAD placement. Feedback from the RFM was used to assess correct/incorrect placement and optimize ventilation quality. The parameter leakage was used for assessment: if leak was <30%, correct placement was assumed. The primary outcome was the number of attempts until correct placement. Secondary outcomes included ventilation parameters recorded by the RFM and the duration of SAD placement.

RESULTS

Six patients were included in this pilot trial. Using a RFM to guide SAD placement led to fewer attempts (median attempts: 3 [hidden] vs. 1 [visible]). Furthermore, using the RFM, necessary adaptations were made to the SAD position to decrease leakage (mean leakage: 74.8% [hidden] vs. 17.8% [visible]), subsequently endoscopy after insertion of SAD using the RFM then confirmed anatomically correct position.

CONCLUSION

This pilot study indicated that a RFM might be useful to provide guidance during SAD placement.

IMPACT STATEMENT

Feedback from a RFM reliably indicated correct anatomical placement of a SAD by correlating low leakage values with proper SAD positioning. RFM guidance could improve neonatal airway management, reducing procedural time and number of attempts. We present promising preliminary results. Further research is needed to confirm these findings.

Evaluating post-cardiac arrest blood pressure thresholds associated with neurologic outcome in children: Insights from the pediRES-Q database

BACKGROUND

Current Pediatric Advanced Life Support Guidelines recommend maintaining blood pressure (BP) above the 5th percentile for age following return of spontaneous circulation (ROSC) after cardiac arrest (CA). Emerging evidence suggests that targeting higher thresholds, such as the 10th or 25th percentiles, may improve neurologic outcomes. We aimed to evaluate the association between post-ROSC BP thresholds and neurologic outcome, hypothesizing that maintaining mean arterial pressure (MAP) and systolic blood pressure (SBP) above these thresholds would be associated with improved outcomes at hospital discharge.

METHODS

This retrospective, multi-center, observational study analyzed data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q). Children (<18 years) who achieved ROSC following index in-hospital or out-of-hospital cardiac arrest and survived ≥ 6 h were included. Multivariable logistic regression was preformed to analyze the association between the pre-defined BP thresholds (5th, 10th, and 25th percentiles) and favorable neurologic outcome, controlling for illness category (surgical-cardiac), initial rhythm (shockable), arrest time (weekend or night), age, CPR duration, and clustering by site.

RESULTS

There were 787 patients with evaluable MAP data and 711 patients with evaluable SBP data. Fifty-four percent (N = 424) of subjects with MAP data and 53 % (N = 380) with SBP data survived to hospital discharge with favorable neurologic outcome. MAP above the 5th, 10th, and 25th percentile thresholds was associated with significantly greater odds of favorable outcome compared to patients with MAP below target (aOR, 1.81 [95 % CI, 1.32, 2.50]; 1.50 [95 % CI, 1.10, 2.05]; 1.40 [95 % CI, 1.01, 1.94], respectively). Subjects with lowest SBP above the 5th percentile also had greater odds of favorable outcome (aOR, 1.44 [95 % CI, 1.04, 2.01]). Associations between lowest SBP above the 10th percentile and 25th percentile did not reach statistical significance (aOR 1.33 [95 % CI, 0.96, 1.86]; 1.23 [95 % CI, 0.87, 1.75], respectively).

CONCLUSION

After pediatric CA, maintaining MAP above the 5th, 10th, and 25th percentiles and SBP above the 5th percentile during the first 6 h following ROSC was significantly associated with improved neurologic outcomes.

To intubate or to resuscitate: the effect of simulation-based training on advanced airway management during simulated paediatric resuscitations

BACKGROUND

We aimed to measure the effect of a 2-day structured paediatric simulation-based training (SBT) on basic and advanced airway management during simulated paediatric resuscitations.

METHODS

Standardised paediatric high-fidelity SBT was conducted in 12 of the 15 children's hospitals in Hesse, Germany. Before and after the SBT the study participants took part in two study scenarios (PRE and POST scenario), which were recorded using an audio-video system. Airway management was assessed using a performance evaluation checklist. Time to initiate ventilation, frequency, and timing of endotracheal intubation (ETI), and its influence on other life support interventions were assessed. Differences in airway management between hospitals with and without a PICU were evaluated.

RESULTS

Two hundred twenty-nine participants formed 58 interprofessional resuscitation teams. All teams recognised apnoea in their simulated patients and initiated ventilation during the scenarios. Time to recognition of apnoea and time to initiation of ventilation did not improve significantly after SBT, but teams were significantly more likely to select appropriately sized airway equipment. ETI was attempted in 55% PRE and 40% POST scenarios (p=0.1). The duration of the entire ETI process was significantly shorter in the POST scenarios. Chest compressions (CC) were frequently discontinued during ETI attempts, which improved after SBT (PRE 73% vs. POST 43%, p = 0.035). Adequate resumption of CC after completion of intubation was also significantly more frequent in the POST scenarios (46% vs. 74%, p = 0.048). During ETI attempts, CC were more likely to be adequately continued in teams from hospitals with a PICU (PRE scenarios: PICU 20% vs. NON-PICU 36%; POST scenarios: PICU 79%, NON-PICU 22%; p < 0.01).

CONCLUSIONS

Our data suggest an association between airway management complexity and basic life support measures. Although the frequency of ETI was not significantly reduced after a 2-day SBT intervention, the duration of advanced airway management was shortened thus reducing no-ventilation time which led to fewer interruptions in chest compressions during simulated paediatric resuscitations. SBT may be adapted to the participants' workplace to maximize its effect and improve the overall performance in paediatric resuscitation.

Effect Size of Targeted Temperature Management in Pediatric Patients with Post-Cardiac Arrest Syndrome According to the Severity

AIM

Few studies have investigated the differential effects of targeted temperature management (TTM) according to the severity of the condition in pediatric patients with post-cardiac arrest syndrome (PCAS). This study was aimed at evaluating the differential effects of TTM in pediatric patients with PCAS according to a risk classification tool developed by us, the rCAST.

METHODS

We used data from a nationwide prospective registry for out-of-hospital cardiac arrest (OHCA) patients in Japan. We classified eligible pediatric PCAS patients (aged ≤ 18 years) into quintiles based on their rCAST scores and evaluated the effect of TTM on the neurological outcomes in each severity group. Then, focusing on the severity group that appeared to benefit from TTM, we also evaluated the effect of TTM by propensity score analysis. Good neurological outcome was defined as a score on the Cerebral Performance Category or Pediatric Cerebral Performance Category scale of ≤2 at 30 days.

RESULTS

Among 1526 OHCA pediatric patients enrolled in the registry, the data of 307 PCAS patients were analyzed. None of the patients in the fifth quintile (rCAST ≥ 18.5) showed a good neurological outcome, regardless of whether they received TTM or not (0% [0/20] vs. 0% [0/73]). The propensity score analysis showed that TTM was significantly associated with a good neurological outcome in patients with rCAST scores in the first to fourth quintile (odds ratio: 1.21 [1.04-1.40], p = 0.014).

CONCLUSIONS

TTM was significantly associated with good neurological outcomes in pediatric PCAS patients with rCAST scores of ≤18.0.

Prolonged Capillary Refill Time as an Early Sign of Compromised Circulation in an Infant With Supraventricular Tachycardia: A Case Report

Capillary refill time (CRT) is a valuable clinical sign in pediatric assessment, particularly in evaluating circulatory status. We present a case of a one-month-old infant with supraventricular tachycardia (SVT), who demonstrated prolonged CRT, emphasizing the importance of this physical examination finding in the context of other signs of compromised circulation.

Is It Possible to Perform Quality Neonatal CPR While Maintaining Skin-to-Skin Contact? A Crossover Simulation Study

Background: This study aimed to assess the feasibility and quality of resuscitation maneuvers performed on a newborn over the mother's body while maintaining SSC and delayed cord clamping. Methods: A randomized crossover manikin study compared standard cardiopulmonary resuscitation (Std-CPR) and cardiopulmonary resuscitation during SSC (SSC-CPR). Nursing students (n = 40) were recruited and trained in neonatal CPR. The quality of the CPR, including compression and ventilation variables, was evaluated using Laerdal Resusci Baby QCPR® manikins. Findings: No significant differences were found in the compression variables between the Std-CPR and the SSC-CPR. The quality variables demonstrated comparable results between the two techniques. The quality of the compressions showed medians of 74% for the Std-CPR and 74% for the SSC-CPR (p = 0.79). Similarly, the quality of the ventilations displayed medians of 94% for the Std-CPR and 96% for the SSC-CPR (p = 0.12). The overall CPR quality exhibited medians of 75% for the Std-CPR and 82% for the SSC-CPR (p = 0.06). Conclusions: Performing CPR on a newborn over the mother's body during SSC is feasible and does not compromise the quality of resuscitation maneuvers. This approach may offer advantages in preserving maternal-newborn bonding and optimizing newborn outcomes. Further studies are needed to address the limitations of this research, including the use of simulations that may not fully replicate real-life conditions, the lack of analysis of different types of labor, and the unpredictability of the maternal response during resuscitation.

Impact of COVID-19 mitigation measures on perinatal outcomes in the Netherlands

OBJECTIVE

Investigate the acute impact of COVID-19 mitigation measures implemented in March 2020 on a comprehensive range of perinatal outcomes.

STUDY DESIGN

National registry-based quasi-experimental study.

METHODS

We obtained data from the Dutch Perinatal Registry (2010-2020) which was linked to multiple population registries containing sociodemographic variables. A difference-in-discontinuity approach was used to examine the impact of COVID-19 mitigation measures on various perinatal outcomes. We investigated preterm birth incidence across onset types, alongside other perinatal outcomes including low birth weight, small-for-gestational-age, NICU admission, low-APGAR-score, perinatal mortality, neonatal death, and stillbirths.

RESULTS

The analysis of the national-level dataset revealed a consistent pattern of reduced preterm births after the enactment of COVID-19 mitigation measures on March 9, 2020 (OR = 0.80, 95% CI 0.68-0.96). A drop in spontaneous preterm births post-implementation was observed (OR = 0.80, 95% CI 0.62-0.98), whereas no change was observed for iatrogenic births. Regarding stillbirths (OR = 0.95, 95% CI 0.46-1.95) our analysis did not find compelling evidence of substantial changes. For the remaining outcomes, no discernible shifts were observed.

CONCLUSIONS

Our findings confirm the reduction in preterm births following COVID-19 mitigation measures in the Netherlands. No discernible changes were observed for other outcomes, including stillbirths. Our results challenge previous concerns of a potential increase in stillbirths contributing to the drop in preterm births, suggesting alternative mechanisms.

The influence of depth of sedation on motor evoked potentials monitoring in youth from 4 to 23 years old: preliminary data from a prospective observational study

Introduction

The influence of various levels of sedation depth on motor evoked potentials (MEP) reproducibility in youth is still unclear because of a lack of data. We tested the hypothesis that a deeper level of total intravenous anesthesia (TIVA) [bispectral index (BIS) 40 ± 5 compared to 60 ± 5] can affect surgeon-directed MEP and their interpretation in youths.

Methods

All patients received TIVA combined with propofol and remifentanil. TIVA was initially maintained at a BIS level of 60 ± 5. The sedation anesthesia was deepened to BIS level 40 ± 5 before the skin incision. MEP were recorded and interpreted at both BIS levels. The primary endpoint was to evaluate the effect of the depth of sedation on the MEP reproducibility directed and interpreted by the surgical team in each patient separately. The secondary endpoint was to compare the relativized MEP parameters (amplitude and latency) in percentage at various levels of sedation in each patient separately. We planned to enroll 150 patients. Due to the COVID-19 pandemic, we decided to analyze the results of the first 50 patients.

Results

The surgical team successfully recorded and interpreted MEP in all 50 enrolled patients in both levels of sedation depth without any clinical doubts. The MEP parameters at BIS level 40 ± 5, proportionally compared with the baseline, were latency 104% (97-110%) and the MEP amplitudes 84.5% (51-109%).

Conclusion

Preliminary data predict that deeper sedation (BIS 40 ± 5) does not affect the surgical team's interpretation of MEP in youth patients. These results support that surgeon-directed MEP may be an alternative when neurophysiologists are unavailable.

Proportional Versus Fixed Chest Compression Depth for Guideline-Compliant Resuscitation of Infant Asphyxial Cardiac Arrest

OBJECTIVES

Current guidelines for parameters of the delivery of chest compressions (CC) for infants and children are largely consensus based. Of the two recommended depth targets - 1.5 inches and 1/3 anterior-posterior chest diameter (APD) - it is unclear whether these have equal potential for injury. In previous experiments, our group showed in an animal model of pediatric asphyxial out-of-hospital cardiac arrest (OHCA; modeling ∼ 7 year-old children) that 1/3 APD resulted in significantly deeper CC and a higher likelihood of life-threatening injury. We sought to examine and compare injury characteristics of CC delivered at 1.5 inches or 1/3 APD in an infant model of asphyxial OHCA.

METHODS

Swine were sedated, anesthetized, paralyzed, intubated through direct laryngoscopy, and then mechanically ventilated (10 ml/kg, FiO2:21%). APD was measured and confirmed by two investigators via a sliding T-square at the xiphoid. After instrumentation for vital signs monitoring, and while still anesthetized, the endotracheal tube was manually occluded to induce asphyxia, and occlusion was maintained for 9 min. Animals were then randomized to receive CC with a depth of 1.5 inches (Group 1) or 1/3 APD (Group 2), both with a rate of 100 per minute. Advanced life support drugs were administered at 13 min, and defibrillation at 14 min. Resuscitation continued until return of spontaneous circulation (ROSC) or 20 min of failed resuscitation. Survivors were sacrificed with KCl after 20 min of observation. Veterinary staff conducted necropsy to assay lung injury, rib fracture, hemothorax, airway bleeding, great vessel dissection, and heart/liver/spleen contusion. Injury characteristics were summarized and compared via Chi-Squared test or Mann-Whitney U-test using an alpha = 0.05.

RESULTS

A total of 36 animals were included for analysis (Group 1: 18; Group 2: 18). Mean (SD) APD overall was 5.58 (0.23) inches, yielding a mean 1/3 APD depth of 1.86 inches. APD did not differ between groups. ROSC rates did not differ between groups. No injury characteristics differed significantly between groups.

CONCLUSIONS

In an swine model of infant asphyxial OHCA and resuscitation considering 1/3 APD or 1.5 inches, neither CC depth strategy was associated with increased injury.

Effectiveness of intraosseous access during resuscitation: a retrospective cohort study

PURPOSE

During resuscitation in emergency situations, establishing intravascular access is crucial for promptly initiating delivery of fluids, blood, blood products, and medications. In cases of emergency, when intravenous (IV) access proves unsuccessful, intraosseous (IO) access serves as a viable alternative. However, there is a notable lack of information concerning the frequency and efficacy of IO access in acute care settings. This study aims to assess the efficacy of intraosseous (IO) access in acute care settings, especially focusing on children in a level 1 trauma center.

METHODS

This retrospective study included patients with IO access presented in a level 1 trauma center emergency department (ED) between January 2015 and April 2020. Data regarding medication and fluid infusion was documented, and the clinical success rate was calculated.

RESULTS

Of the 109,548 patients that were admitted to the ED, 25,686 IV lines were inserted. Documentation of 188 patients of which 73 (38.8%) children was complete and used for analysis. In these 188 patients, a total of 232 IO accesses were placed. Overall, 182 patients had a functional IO access (204 needles) (88%). In children (age < 18 years) success rate was lower as compared to adults, 71-84% as compared to 94%. However, univariate regression showed no association between the percentage of functional IO access and gender, age, weight, health care location (prehospital and in hospital), anatomical position (tibia as compared to humerus) or type of injury.

CONCLUSION

Intraosseous access demonstrates a high success rate for infusion, independent of gender, age, weight, anatomical positioning, or healthcare setting, with minimal complication rates. Caution is especially warranted for children under the age of six months, since success rate was lower.

Pathophysiology and Prevention of Manual-Ventilation-Induced Lung Injury (MVILI)

Manual ventilation, most commonly with a bag-valve mask, is a form of short-term ventilation used during resuscitative efforts in emergent and out-of-hospital scenarios. However, compared to mechanical ventilation, manual ventilation is an operator-dependent skill that is less well controlled and is highly subject to providing inappropriate ventilation to the patient. This article first reviews recent manual ventilation guidelines set forth by the American Heart Association and European Resuscitation Council for providing appropriate manual ventilation parameters (e.g., tidal volume and respiratory rate) in different patient populations in the setting of cardiopulmonary resuscitation. There is then a brief review of clinical and manikin-based studies that demonstrate healthcare providers routinely hyperventilate patients during manual ventilation, particularly in emergent scenarios. A discussion of the possible mechanisms of injury that can occur during inappropriate manual hyperventilation follows, including adverse hemodynamic alterations and lung injury such as acute barotrauma, gastric regurgitation and aspiration, and the possibility of a subacute, inflammatory-driven lung injury. Together, these injurious processes are described as manual-ventilation-induced lung injury (MVILI). This review concludes with a discussion that highlights recent progress in techniques and technologies for minimizing manual hyperventilation and MVILI, with a particular emphasis on tidal-volume feedback devices.

Extracorporeal cardiopulmonary resuscitation for pediatric out-of-hospital cardiac arrest: A review of the Extracorporeal Life Support Organization Registry

AIMS

Current data are insufficient for the leading resuscitation societies to advise on the use of extracorporeal cardiopulmonary resuscitation (ECPR) for pediatric out-of-hospital cardiac arrest (OHCA). The aim of this study was to explore the current utilization of ECPR for pediatric OHCA and characterize the patient demographics, arrest features, and metabolic parameters associated with survival.

METHODS

Retrospective review of the Extracorporeal Life Support Organization Registry database from January 2020 to May 2023, including children 28 days to 18 years old who received ECPR for OHCA. The primary outcome was survival to hospital discharge.

RESULTS

Eighty patients met inclusion criteria. Median age was 8.8 years [2.0-15.8] and 53.8% of patients were male. OHCA was witnessed for 65.0% of patients and 46.3% received bystander cardiopulmonary resuscitation (CPR). Initial rhythm was shockable in 26.3% of patients and total CPR duration was 78 min [52-106]. Signs of life were noted for 31.3% of patients and a cardiac etiology precipitating event was present in 45.0%. Survival to discharge was 29.9%. Initial shockable rhythm was associated with increased odds of survival (unadjusted OR 4.7 [1.5-14.5]; p = 0.006), as were signs of life prior to ECMO (unadjusted OR 7.8 [2.6-23.4]; p < 0.001). Lactate levels early on-ECMO (unadjusted OR 0.89 [0.79-0.99]; p = 0.02) and at 24 h on-ECMO (unadjusted OR 0.62 [0.42-0.91]; p < 0.001) were associated with decreased odds of survival.

CONCLUSIONS

These preliminary data suggest that while overall survival is poor, a carefully selected pediatric OHCA patient may benefit from ECPR. Further studies are needed to understand long-term neurologic outcomes.

Optimal Chest Compression Point During Pediatric Resuscitation: Implications for Pediatric Resuscitation Practice by CT Scans

OBJECTIVES

Current European guidelines for pediatric cardiopulmonary resuscitation (CPR) recommend the lower half of the sternum as the chest compression point (CP). In this study, we have used thoracic CT scans to evaluate recommended and optimal CP in relation to cardiac anatomy and structure.

DESIGN

Analysis of routinely acquired thoracic CT scans acquired from 2000 to 2020.

SETTING

Single-center pediatric department in a German University Hospital.

PATIENTS

Imaging data were obtained from 290 patients of 3-16 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured and analyzed 14 thoracic metrics in each thoracic CT scan. In 44 of 290 (15.2%) scans, the recommended CP did not match the level of the cardiac ventricles. Anatomically, the optimal CP was one rib or one vertebral body lower than the recommended CP, that is, the optimal CP was more caudal to the level of the body of the sternum in 67 of 290 (23.1%) scans. The recommended compression depth appeared reasonable in children younger than 12 years old. At 12 years old or older, the maximum compression depth of 6 cm is less than or equal to one-third of the thoracic depth.

CONCLUSIONS

In this study of thoracic CT scans in children 3-16 years old, we have found that optimal CP for CPR appears to be more caudal than the recommended CP. Therefore, it seems reasonable to prefer to use the lower part of the sternum for CPR chest compressions. At 12 years old or older, a compression depth similar to that used in adults-6 cm limit-may be chosen.

Methods of Using a Manual Defibrillator during Simultaneous Cardiac Arrest in Two Patients-Analysis of the Actions of Emergency Medical Response Teams during the Championships in Emergency Medicine

Background/Objectives: Conducting advanced resuscitation requires medical personnel to carry out appropriately coordinated actions. Certain difficulties arise when it becomes necessary to conduct cardiopulmonary resuscitation (CPR) on two patients at the same time. The aim of this paper was to assess the actions of teams participating in emergency medicine championships in tasks related to simultaneous cardiac arrests in two patients. Methods: The study was conducted on the basis of an analysis of assessment cards for tasks carried out during the 'International Winter Championships in Emergency Medicine'. Three-person medical response teams (MRTs), with the support of two people, had the task of conducting advanced resuscitation on an adult and child simultaneously. The tasks were prepared and developed by European Resuscitation Council (ERC) instructors. Results: The study showed that teams used four methods of checking heart rhythm and performing defibrillation during CPR-using paddles only, using paddles and self-adhesive electrodes, using paddles and a three-lead ECG and using two pairs of self-adhesive electrodes. Teams performing cardiopulmonary resuscitation using paddles and a three-lead ECG performed significantly more actions incorrectly than other teams-in part due to the fact that they incorrectly interpreted which patient's heart rhythm was displayed on the defibrillator screen. The effectiveness of the remaining methods was similar for most of the actions. The CPR method using two pairs of electrodes enabled personal safety to be maintained to the significantly highest percentage during defibrillation. Conclusions: The study demonstrated that the need to conduct CPR on two patients at the same time, irrespective of the method used, caused MRT members considerable difficulties in correctly conducting some of the actions. The method of assessing heart rhythm using paddles and a three-lead ECG should not be used. The study showed that the optimal method of CPR in use appears to be the method using two pairs of adhesive electrodes-it provided, among other things, the significantly highest percentage of safely conducted defibrillation.

Knowledge and skills of pediatric residents in managing pediatric foreign body airway obstruction using novel airway clearance devices in Spain: A randomized simulation trial

Aim

Recent emergence of airway clearance devices (ACDs) as a treatment alternative for foreign body airway obstructions (FBAO) lacks substantial evidence on efficacy and safety. This study aimed to assess pediatric residents' knowledge and skills in managing a simulated pediatric choking scenario, adhering to recommended protocols, and using LifeVac© and DeCHOKER© ACDs.

Methods

Randomized controlled simulation trial, in which 60 pediatric residents from 3 different hospitals (median age 27 [25.0-29.9]; 76.7% female) were asked to solve an unannounced pediatric simulated choking scenario using three interventions to manage (randomized order): 1) following the recommended protocol of the European Resuscitation Council (encouraging to cough or combination of back blows and abdominal thrusts); 2) using LifeVac©; and 3) using DeCHOKER©. A Little Anne QCPR™ manikin (Laerdal Medical) was used. The variable compliance rate (%) was calculated according to the correct/incorrect execution of the steps constituting the proper actions for each test.

Results

Participants demonstrated a correct compliance rate only ranging between 50-75% in following the recommended protocol for managing partial FBAO progressing to severe. Despite unfamiliarity with the ACDs, pediatric residents achieved rates between 75% and 100%, with no significant difference noted between the two devices (p = 0.173). Both scenarios were successfully resolved in under a minute, with LifeVac© demonstrating a significantly shorter response time compared to DeCHOKER© (39.2 [30.4-49.1] vs. 45.1s [33.7-59.2], p = 0.010).

Conclusions

Only a minority of pediatric residents were able to adhere to the recommended FBAO protocol, whereas 70% of them were able to adequately use the ACDs. However, since a significant proportion could not, it seems that ACDs themselves do not address all issues.

What Mistakes Can Be Made When Performing the Electrical Cardioversion Procedure?-Analysis of Emergency Medical Team Performance during the Championships in Emergency Medicine

BACKGROUND

Medical personnel carrying out electrical cardioversion (EC) procedures must remember to have the R-wave sync mode switched on, use the correct energy and maintain personal safety. The defibrillators used by medical response teams most often switch out of cardioversion mode once a shock is delivered. Therefore, this mode must be switched on again before subsequent shocks are delivered. The main aim of the study was to assess the ability of emergency medical teams participating in emergency medicine championships to perform EC.

METHODS

The research was a retrospective observational study and was based on an analysis of the evaluation sheets from two tasks simulating the management of a patient with unstable tachycardia conducted during the International Winter Emergency Medicine Championships. Three-person teams consisting of paramedics and representing the Polish emergency services were included in the study. The team representing the championship organiser and the few foreign teams participating in the competition were excluded from the study.

RESULTS

The decision to conduct EC was taken by 36 teams (83.72%) in 2015 and 27 teams (87.10%) in 2019. In both editions of the championships, during consecutive shocks, the percentage of actions performed correctly decreased significantly-switching on synchronisation mode in 2015 (94.4%, 83.33%, 72.22%) and in 2019 (100%, 88.89%, 81.48%); correct energies in 2015 (91.67%, 80.56%, 77.78%) and in 2019 (92.59%, 85.19%, 81.48%); shocks in a safe manner in 2015 (94.44%, 94.44%, 91.67%) and in 2019 (100%, 96.30%, 96.30%).

CONCLUSIONS

Teams participating in the assessed tasks in a significant majority of cases correctly qualified the patient for EC, and correctly carried out the actions required for this procedure. It is of particular note that with every subsequent shock, the percentage of shocks carried out without the sync mode increased significantly.

Cancer is not a risk factor for severe COVID-19 in children, except in patients with recent allogeneic hematopoietic stem cell transplantation or comorbidities

The EPICO (Spanish general registry of COVID-19 in children)-SEHOP (Spanish Society of Pediatric Hematology and Oncology) platform gathers data from children with SARS-CoV-2 in Spain, allowing comparison between children with cancer or allogeneic hematopoietic stem cell transplantation (alloHSCT) and those without. The infection is milder in the cancer/alloHSCT group than in children without comorbidities (7.1% vs. 14.7%), except in children with recent alloHSCT (less than 300 days), of which 35.7% experienced severe COVID-19. These data have been shared with the SEHOP members to support treatment and isolation policies akin to those for children without cancer, except for those with recent alloHSCT or additional comorbidities. This highlights the collaborative registries potential in managing pandemic emergencies.

ILCOR pediatric life support recommendations translation to constituent council guidelines: An emphasis on similarities and differences

The International Liaison Committee on Resuscitation (ILCOR) performs rigorous scientific evidence evaluation and publishes Consensus on Science with Treatment Recommendations. These evidence-based recommendations are incorporated by ILCOR constituent resuscitation councils to inform regional guidelines, and further translated into training approaches and materials and implemented by laypersons and healthcare providers in- and out-of-hospital. There is variation in council guidelines as a result of the weak strength of evidence and interpretation. In this manuscript, we highlight ten important similarities and differences in regional council pediatric resuscitation guidelines, and further emphasize three differences that identify key knowledge gaps and opportunity for "natural experiments."

Evaluation of basic life support interventions for foreign body airway obstructions: A population-based cohort study

AIM

To quantify the associations of foreign body airway obstruction (FBAO) basic life support (BLS) interventions with FBAO relief and survival to discharge.

METHODS

We identified prehospital FBAO patient encounters in Alberta, Canada between Jan 1, 2018 and Dec 31,2021 using the provincial emergency medical services' medical records, deterministically linked to hospital data. Two physicians reviewed encounters to determine cases and extract data. Multivariable logistic regression determined the adjusted odds ratio of FBAO relief (primary outcome) and survival to discharge for the exposure of BLS interventions (abdominal thrusts [AT], chest compressions/thrusts [CC], or combinations) relative to back blows [BB]. Intervention-associated injuries were identified using International Classification of Diseases codes, followed by health records review.

RESULTS

We identified 3,677 patient encounters, including 709 FBAOs requiring intervention. Bystanders performed the initial BLS intervention in 488 cases (77.4%). Bystanders and paramedics did not relieve the FBAO in 151 (23.5%) and 11 (16.7%) cases, respectively. FBAOs not relieved before paramedic arrival had a higher proportion of deaths (n = 4[0.4%] versus n = 92[42.4%], p < 0.001). AT and CC were associated with decreased odds of FBAO relief relative to BB (adjusted odds ratio [aOR] 0.49 [95%CI 0.30-0.80] and 0.14 [95%CI 0.07-0.28], respectively). CC were associated with decreased odds of survival to discharge (aOR 0.04 [95%CI 0.01-0.32]). AT, CC, and BB were implicated in intervention-associated injuries in four, nine, and zero cases, respectively.

CONCLUSIONS

Back blows are associated with improved outcomes compared to abdominal thrusts and chest compressions. These data can inform prospective studies aimed at improving response to choking emergencies.

Successful Intraosseous (IO) Adenosine Administration for the Termination of Supraventricular Tachycardia (SVT) in a 3.5-Year-Old Child-Case Report and Literature Review

Paediatric supraventricular tachycardia (SVT) is a common arrhythmia of great clinical significance. If not treated promptly, it can cause heart failure and cardiogenic shock. Depending on the patient's condition, SVT treatment involves vagal manoeuvres, pharmacological, or direct current cardioversion. The goal of acute SVT management is to immediately convert SVT to a normal sinus rhythm (NSR) and prevent its recurrence. Adenosine is recommended as the first-line treatment for stable SVT by the European Resuscitation Council (ERC) and American Heart Association (AHA) guidelines, when vagal manoeuvres have proven ineffective. The ERC and AHA guidelines recommend the intravenous route of administration. The intraosseous (IO) administration technique is also possible, but still relatively unknown. The aim of this paper is to describe a 3.5-year-old child with SVT that was converted to NSR following IO administration of adenosine. Successful conversion was achieved after the second attempt with the adenosine dose. In the described case, there was no recurrence of SVT.

Is It Feasible to Perform Infant CPR during Transfer on a Stretcher until Cannulation for Extracorporeal CPR? A Randomization Simulation Study

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) improves infant survival outcomes after cardiac arrest. If not feasible at the place of arrest, victims must be transported to a suitable room to perform ECMO while effective, sustained resuscitation maneuvers are performed. The objective of this simulation study was to compare the quality of resuscitation maneuvers on an infant manikin during simulated transfer on a stretcher (stretcher test) within a hospital versus standard stationary resuscitation maneuvers (control test).

METHODS

A total of 26 nursing students participated in a randomized crossover study. In pairs, the rescuers performed two 2 min tests, consisting of five rescue breaths followed by cycles of 15 compressions and two breaths. The analysis focused on CPR variables (chest compression and ventilation), CPR quality, the rate of perceived exertion and the distance covered.

RESULTS

No differences were observed in the chest compression quality variable (82 ± 10% versus 84 ± 11%, p = 0.15). However, significantly worse values were observed in the test for ventilation quality on the stretcher (18 ± 14%) compared to the control test (28 ± 21%), with a value of p = 0.030. Therefore, the overall CPR quality was worse in the stretcher test (50 ± 9%) than in the control test (56 ± 13%) (p = 0.025).

CONCLUSIONS

Infant CPR performed by nursing students while walking alongside a moving stretcher is possible. However, in this model, the global CPR quality is less due to the low ventilation quality.

Early bolus epinephrine administration during pediatric cardiopulmonary resuscitation for bradycardia with poor perfusion: an ICU-resuscitation study

BACKGROUND

Half of pediatric in-hospital cardiopulmonary resuscitation (CPR) events have an initial rhythm of non-pulseless bradycardia with poor perfusion. Our study objectives were to leverage granular data from the ICU-RESUScitation (ICU-RESUS) trial to: (1) determine the association of early epinephrine administration with survival outcomes in children receiving CPR for bradycardia with poor perfusion; and (2) describe the incidence and time course of the development of pulselessness.

METHODS

Prespecified secondary analysis of ICU-RESUS, a multicenter cluster randomized trial of children (< 19 years) receiving CPR in 18 intensive care units in the United States. Index events (October 2016-March 2021) lasting ≥ 2 min with a documented initial rhythm of bradycardia with poor perfusion were included. Associations between early epinephrine (first 2 min of CPR) and outcomes were evaluated with Poisson multivariable regression controlling for a priori pre-arrest characteristics. Among patients with arterial lines, intra-arrest blood pressure waveforms were reviewed to determine presence of a pulse during CPR interruptions. The temporal nature of progression to pulselessness was described and outcomes were compared between patients according to subsequent pulselessness status.

RESULTS

Of 452 eligible subjects, 322 (71%) received early epinephrine. The early epinephrine group had higher pre-arrest severity of illness and vasoactive-inotrope scores. Early epinephrine was not associated with survival to discharge (aRR 0.97, 95%CI 0.82, 1.14) or survival with favorable neurologic outcome (aRR 0.99, 95%CI 0.82, 1.18). Among 186 patients with invasive blood pressure waveforms, 118 (63%) had at least 1 period of pulselessness during the first 10 min of CPR; 86 (46%) by 2 min and 100 (54%) by 3 min. Sustained return of spontaneous circulation was highest after bradycardia with poor perfusion (84%) compared to bradycardia with poor perfusion progressing to pulselessness (43%) and bradycardia with poor perfusion progressing to pulselessness followed by return to bradycardia with poor perfusion (62%) (p < 0.001).

CONCLUSIONS

In this cohort of pediatric CPR events with an initial rhythm of bradycardia with poor perfusion, we failed to identify an association between early bolus epinephrine and outcomes when controlling for illness severity. Most children receiving CPR for bradycardia with poor perfusion developed subsequent pulselessness, 46% within 2 min of CPR onset.

Extracorporeal cardiopulmonary resuscitation outcomes for children with out-of-hospital and emergency department cardiac arrest

OBJECTIVE

Data suggest extracorporeal cardiopulmonary resuscitation (ECPR) improves survival in adult patients with refractory cardiac arrest; however, ECPR outcomes in pediatric patients with out-of-hospital cardiac arrest (OHCA) is lacking. The primary aim of this study was to characterize pediatric patients who experience OHCA or cardiac arrest in the ED (EDCA). The secondary aim was to examine associations of cardiac arrest and location of ECPR cannulation with mortality.

METHODS

We performed a retrospective analysis of the Extracorporeal Life Support Organization registry. We included pediatric patients (age > 28 days to <18 years) who received ECPR for refractory OHCA or EDCA between 2010 and 2019. Patient, cardiac arrest, and ECPR cannulation characteristics were summarized. We examined associations of location of cardiac arrest and ECPR cannulation with in-hospital mortality using multivariable logistic regression.

RESULTS

We analyzed data from 140 pediatric patients. 66 patients (47%) experienced OHCA and 74 patients (53%) experienced EDCA. Overall survival to hospital discharge was 31% (20% OHCA survival vs. 41% EDCA survival, p = 0.008). In adjusted analyses, OHCA was associated with 3.9 times greater odds of mortality (95% confidence interval [CI] 1.61, 9.81) when compared to compared to EDCA. The location of ECPR cannulation was not associated with mortality (odds ratio 1.8, 95% CI 0.75, 4.3).

CONCLUSIONS

The use of ECPR for pediatric patients with refractory OHCA is associated with poor survival compared to patients with EDCA. Location of ECPR cannulation does not appear to be associated with mortality.

Dispatcher-assistance in lay rescuer infant CPR: Promoting the enhancement of the guiding protocol

In the 2021 guidelines of the European Resuscitation Council (ERC) on infant CPR, a two-thumb encircling technique (TTET) is advised instead of the former two-finger technique (TFT), even for single rescuers. It is however unclear if this is also feasible and effective in case of dispatcher-assisted CPR by untrained bystanders and was explored in a cross-over infant manikin study including CPR-trained students and lay people. Both groups performed the TTET and the TFT, with dispatcher-assistance (according to Belgian protocol) only being provided to the CPR-untrained group. Results suggest it is feasible to advice single lay rescuers to perform TTET as part of a dispatcher-assisted CPR protocol, although we identified an ongoing risk, regardless of the technique advised, of suboptimal compression depth. Further research should be performed to confirm these preliminary data and explore optimal protocols for dispatcher-assisted infant CPR.

[Airway management in neonates and infants : Recommendations according to the ESAIC/BJA guidelines]

Securing an airway enables the oxygenation and ventilation of the lungs and is a potentially life-saving medical procedure. Adverse and critical events are common during airway management, particularly in neonates and infants. The multifactorial reasons for this include patient-dependent, user-dependent and also external factors. The recently published joint ESAIC/BJA international guidelines on airway management in neonates and infants are summarized with a focus on the clinical application. The original publication of the guidelines focussed on naming formal recommendations based on systematically documented evidence, whereas this summary focusses particularly on the practicability of their implementation.

Management of Paediatric Cardiac Arrest due to Shockable Rhythm-A Simulation-Based Study at Children's Hospitals in a German Federal State

(1) Background: To improve the quality of emergency care for children, the Hessian Ministry for Social Affairs and Integration offered paediatric simulation-based training (SBT) for all children's hospitals in Hesse. We investigated the quality of paediatric life support (PLS) in simulated paediatric resuscitations before and after SBT. (2) Methods: In 2017, a standardised, high-fidelity, two-day in-house SBT was conducted in 11 children's hospitals. Before and after SBT, interprofessional teams participated in two study scenarios (PRE and POST) that followed the same clinical course of apnoea and cardiac arrest with a shockable rhythm. The quality of PLS was assessed using a performance evaluation checklist. (3) Results: 179 nurses and physicians participated, forming 47 PRE and 46 POST interprofessional teams. Ventilation was always initiated. Before SBT, chest compressions (CC) were initiated by 87%, and defibrillation by 60% of teams. After SBT, all teams initiated CC (p = 0.012), and 80% defibrillated the patient (p = 0.028). The time to initiate CC decreased significantly (PRE 123 ± 11 s, POST 76 ± 85 s, p = 0.030). (4) Conclusions: The quality of PLS in simulated paediatric cardiac arrests with shockable rhythm was poor in Hessian children's hospitals and improved significantly after SBT. To improve children's outcomes, SBT should be mandatory for paediatric staff and concentrate on the management of shockable rhythms.

The pediatric DAV-expert algorithm: A GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access device in children

In pediatric patients, the choice of the venous access device currently relies upon the operator's experience and preference and on the local availability of specific resources and technologies. Though, considering the limited options for venous access in children if compared to adults, such clinical choice has a great critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems fully satisfactory and useful in clinical practice. Thus, the GAVePed-which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT-has developed a national consensus about the choice of the venous access device in children. After a systematic review of the available evidence, the panel of the consensus (which included Italian experts with documented competence in this area) has provided structured recommendations answering 10 key questions regarding the choice of venous access both in emergency and in elective situations, both in the hospitalized and in the non-hospitalized child. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice.

Out-of-hospital cardiac arrest in children in Norway: A national cohort study, 2016-2021

Aim

Children constitute an important and distinct subgroup of out-of-hospital cardiac arrest (OHCA) patients. This population-based cohort study aims to establish current age-specific population incidence, precipitating causes, circumstances, and outcome of paediatric OHCA, to guide a focused approach to prevention and intervention to improve outcomes.

Methods

Data from the national Norwegian Cardiac Arrest Registry was extracted for the six-year period 2016-21 for persons aged <18 years. We present descriptive statistics for the population, resuscitation events, presumed causes, treatment, and outcomes, alongside age-specific incidence and total paediatric mortality rates.

Results

Three hundred and eight children were included. The incidence of OHCA was 4.6 per 100 000 child-years and markedly higher in children <1 year at 20.9 child-years. Leading causes were choking, cardiac and respiratory disease, and sudden infant death syndrome. Overall, 21% survived to 30 days and 18% to one year.

Conclusion

A registry-based approach enabled this study to delineate the characteristics and trajectories of OHCA events in a national cohort of children. Precipitating causes of paediatric OHCA are diverse compared to adults. Infants aged <1 year are at particularly high risk. Mortality is high, albeit lower than for adults in Norway. A rational community approach to prevention and treatment may focus on general infant care, immediate first aid by caretakers, and identification of vulnerable children by primary health providers. Cardiac arrest registries are a key source of knowledge essential for quality improvement and research into cardiac arrest in childhood.

Using generative artificial intelligence in bibliometric analysis: 10 years of research trends from the European Resuscitation Congresses

Aims

The aim of this study is to use generative artificial intelligence to perform bibliometric analysis on abstracts published at European Resuscitation Council (ERC) annual scientific congress and define trends in ERC guidelines topics over the last decade.

Methods

In this bibliometric analysis, the WebHarvy software (SysNucleus, India) was used to download data from the Resuscitation journal's website through the technique of web scraping. Next, the Chat Generative Pre-trained Transformer 4 (ChatGPT-4) application programming interface (Open AI, USA) was used to implement the multinomial classification of abstract titles following the ERC 2021 guidelines topics.

Results

From 2012 to 2022 a total of 2491 abstracts have been published at ERC congresses. Published abstracts ranged from 88 (in 2020) to 368 (in 2015). On average, the most common ERC guidelines topics were Adult basic life support (50.1%), followed by Adult advanced life support (41.5%), while Newborn resuscitation and support of transition of infants at birth (2.1%) was the least common topic. The findings also highlight that the Basic Life Support and Adult Advanced Life Support ERC guidelines topics have the strongest co-occurrence to all ERC guidelines topics, where the Newborn resuscitation and support of transition of infants at birth (2.1%; 52/2491) ERC guidelines topic has the weakest co-occurrence.

Conclusion

This study demonstrates the capabilities of generative artificial intelligence in the bibliometric analysis of abstract titles using the example of resuscitation medicine research over the last decade at ERC conferences using large language models.

Enhancing interprofessional collaboration in paediatric training: Insights from profession-specific experiences and implications for future education

AIM

There is limited evidence on trainees' and instructors' needs and perspectives concerning interprofessional simulation-based trainings. We aimed to study task distribution among team members, profession-specific learning effects and enhancing collaboration and competencies within medical teams.

METHODS

This prospective study examined expectations and experiences of medical and nursing students during paediatric emergency training in a tertiary care centre with questionnaires before and after a training. Further, expert interviews were conducted to identify the needs for interprofessional training. Results were used to design a standardised checklist for structured preparation of interprofessional paediatric emergency management training.

RESULTS

Of the nursing students, 82% initially intended to assume the role of the team leader, but only 5.8% did so during training. Both professions emphasised the significance of effective communication and transparent task distribution for successful collaboration. Experts highlighted the importance of proficiency in basic technical skills and identified non-technical skills such as closed-loop communication and the 10-4-10 principle as crucial for both professions.

CONCLUSION

The study revealed profession-specific variations in the intention of acquiring the team leader or member role. Interprofessional training emerges as a potential strategy to dismantle these structures and promote shared responsibilities. The checklist aims to facilitate structured preparation of a training.

Emergency front-of-neck access in pediatric anesthesia: A narrative review

BACKGROUND AND OBJECTIVES

Children undergoing airway management during general anesthesia may experience airway complications resulting in a rare but life-threatening situation known as "Can't Intubate, Can't Oxygenate". This situation requires immediate recognition, advanced airway management, and ultimately emergency front-of-neck access. The absence of standardized procedures, lack of readily available equipment, inadequate knowledge, and training often lead to failed emergency front-of-neck access, resulting in catastrophic outcomes. In this narrative review, we examined the latest evidence on emergency front-of-neck access in children.

METHODS

A comprehensive literature was performed the use of emergency front-of-neck access (eFONA) in infants and children.

RESULTS

Eighty-six papers were deemed relevant by abstract. Finally, eight studies regarding the eFONA technique and simulations in animal models were included. For all articles, their primary and secondary outcomes, their specific animal model, the experimental design, the target participants, and the equipment were reported.

CONCLUSION

Based on the available evidence, we propose a general approach to the eFONA technique and a guide for implementing local protocols and training. Additionally, we introduce the application of innovative tools such as 3D models, ultrasound, and artificial intelligence, which can improve the precision, safety, and training of this rare but critical procedure.

A severe pediatric life-threatening metabolic ketoacidosis

This case report presents a 9-year-old child without underlying pathology, with a severe life-threatening non-diabetic metabolic ketoacidosis occurring less than 48 h after the onset of fasting and vomiting. The patient was admitted to the pediatric intensive care unit. He received volume expansion and maintenance fluid therapy which allowed a favorable evolution. Because of the unusual rapid onset of intense ketonemia and acidosis, a hereditary metabolic disease was investigated. The association between short fasting period and severe metabolic ketoacidosis has never been described in children outside of the neonatal period. This clinical case emphasizes urgent recognition, rigorous diagnostic and appropriate management in clinical practice.

Update on perioperative fluids

Adequate fluid management in the perioperative period in paediatric patients is essential for restoring and maintaining homeostasis and ensuring adequate tissue perfusion. A well-designed infusion regimen is crucial for preventing severe complications such as hyponatraemic encephalopathies. The composition of perioperative fluid solutions is now guided by an understanding of extracellular fluid physiology. Various crystalloid and colloidal products are available for use, but a comprehensive approach requires careful consideration of their drawbacks and limitations. Additionally, the unique characteristics of different patient groups must be taken into account. This review will provide the reader with physiological considerations for perioperative fluids and describe indications for perioperative intravenous fluid therapy in paediatric patients. The current evidence on perioperative fluid therapy is finally summarised in practical recommendations.

Effects of propofol, ketamine-propofol mixture in pediatric dental patients undergoing intravenous sedation: a clinical study

This study aimed to evaluate the clinical effects, complications (peri- and postoperative), depth of sedation, recovery times, and changes in anxiety levels in paediatric dental patients receiving intravenous sedation with propofol and ketamine-propofol mixtures. This prospective clinical study included 69 healthy children (ASA 1) aged 3-7 years. The patients were assigned randomly to propofol group (n = 23), which received propofol; 1:3 ketofol group (n = 23), which received 1:3 ketofol; or 1:4 ketofol group (n = 23), which received 1:4 ketofol. The bispectral index (BIS) and Ramsay Sedation Scale (RSS) score were recorded at intervals of 5 min to measure the depth of sedation, and vital signs were evaluated. Peri- and postoperative complications and recovery times were recorded. Anxiety levels were also evaluated using the Facial Image Scale (FIS) and changes in saliva cortisol levels (SCLs) before and after the intravenous sedation procedure. The Kruskal‒Wallis test and Wilcoxon signed-rank test were used to determine pre- and posttreatment parameters. Dunn's test for post hoc analysis was used to determine the differences among groups. Children's pre- and posttreatment anxiety levels did not differ significantly according to FIS scores, and increases in SCLs were detected in 1:3 ketofol and 1:4 ketofol groups after dental treatment was completed. Compared with those in the other groups, the BIS values of the patients in 1:4 ketofol indicated a slightly lower depth of sedation. The recovery time of the patients in 1:3 ketofol was longer than that of patients in propofol and 1:4 ketofol. The incidence of postoperative complications (agitation, hypersalivation, nausea/vomiting, and diplopia) did not differ among the groups. Ketamine-propofol combinations provided effective sedation similar to that of propofol infusion without any serious complications during dental treatment performed under intravenous sedation. The ketofol infusion increased the anxiety level of paediatric dental patients to a greater extent than the propofol infusion.

Advantages of bystander-performed conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest presumably caused by drowning in Japan: a propensity score-matching analysis using an extended nationwide database

OBJECTIVES

This study aimed to determine whether the association between conventional bystander cardiopulmonary resuscitation (BCPR) and better outcomes in drowning-associated out-of-hospital cardiac arrest (OHCA) differs between young and older people or between non-medical and medical drowning in Japan.

DESIGN

Observational study.

SETTING

This study used data from the Japanese Fire and Disaster Management Agency databases.

PARTICIPANT

Of the 504 561 OHCA cases recorded in the nationwide database between 2016 and 2019, 16 376 (3.2%) were presumably caused by drowning.

MAIN OUTCOME MEASURE

The main outcomes were a 1-month neurological prognosis defined as cerebral performance category 1 or 2 and 1-month survival as measures.

RESULT

The incidence of drowning as a presumed cause of OHCA was high in the winter and the middle-aged and older generations in Japan. However, OHCA caused by drowning in the younger generation frequently occurs in the summer. Furthermore, younger patients had higher incidences of bystander-witnessed cardiac arrest (22.0%), BCPR provision (59.3%) and arrest in outdoor settings (54.0%) than middle-aged and older generations (5.9%, 46.1% and 18.7% respectively). If the patient was younger or the arrest was accidental, the conventional BCPR group had better neurological outcomes than the compression-only BCPR group (95% CI of adjusted OR, 1.22 to 12.2 and 1.80 to 5.57, respectively). However, in the case of middle-aged and older generations and medical categories, there was no significant difference in outcomes between the two types of BCPR. This conventional group's advantage was maintained even after matching.

CONCLUSION

Conventional bystander CPR yielded a higher neurologically favourable survival rate than compression-only BCPR for OHCA caused by drowning if the patient was younger or the arrest was non-medical. Conventional CPR education for citizens who have the chance to witness drownings should be maintained.

Impact of the COVID-19 pandemic on pediatric out-of-hospital cardiac arrest outcomes in Japan

This study investigates the impact of the COVID-19 pandemic on pediatric out-of-hospital cardiac arrest (OHCA) outcomes in Japan, aiming to address a critical research gap. Analyzing data from the All-Japan Utstein registry covering pediatric OHCA cases from 2018 to 2021, the study observed no significant changes in one-month survival, neurological outcomes, or overall performance when comparing the pre-pandemic (2018-2019) and pandemic (2020-2021) periods among 6765 cases. However, a notable reduction in pre-hospital return of spontaneous circulation (ROSC) during the pandemic (15.1-13.1%, p = .020) was identified. Bystander-initiated chest compressions and rescue breaths declined (71.1-65.8%, 22.3-13.0%, respectively; both p < .001), while bystander-initiated automated external defibrillator (AED) use increased (3.7-4.9%, p = .029). Multivariate logistic regression analyses identified factors associated with reduced pre-hospital ROSC during the pandemic. Post-pandemic, there was no noticeable change in the one-month survival rate. The lack of significant change in survival may be attributed to the negative effects of reduced chest compressions and ventilation being offset by the positive impact of widespread AED availability in Japan. These findings underscore the importance of innovative tools and systems for safe bystander cardiopulmonary resuscitation during a pandemic, providing insights to optimize pediatric OHCA care.

Ventilation efficacy during paediatric cardiopulmonary resuscitation (PEDIVENT): simulation-based comparative study

Introduction

This simulation-based study aimed to evaluate the efficacy of ventilation during paediatric cardiopulmonary resuscitation (CPR) provided by healthcare professionals (HCPs) and lay rescuers (LRs). The objective was to assess the number of effective breaths delivered during the initial sequence of CPR. Effective ventilation plays a critical role during paediatric CPR as most cardiac arrests are secondary to hypoxia in origin. The recommendations on initial resuscitation in unresponsive, non-breathing children differ worldwide. The European Resuscitation Council (ERC) guidelines recommend five breaths before starting the chest compressions. Yet, this recommendation was based on the expert consensus historically and has not changed since 2000 because of the lack of evidence. This research addresses the identified knowledge gap, with potential implications for improving resuscitation practices and ultimately enhancing patient outcomes.

Methods

HCPs and LRs performed 90 s of CPR involving two mannequins: 5-kg Baby and 20-kg Junior. Both groups (HCPs and LRs) performed the task before and after structured CPR training, and the efficacy of ventilation before and after the training was compared. The HCPs provided bag-mask ventilation; LR performed dispatcher-assisted CPR with mouth-to-mouth ventilation.

Results

The number of participants that reached the primary outcome before and after the training in Baby was 26 (65%) vs. 40 (100%) in HCPs and 28 (60.9%) vs. 45 (97.8%) in LRs (improvement in both p < 0.001), respectively. The number of participants that reached the primary outcome before and after the training in the Junior mannequin was 31 (77.5%) vs. 32 (82.1%) in HCPs (p = 0.77) and 32 (82.1%) vs. 37 (94.9%) in LRs (p = 0.005), respectively.

Discussion

This simulation-based study is the first to investigate ventilation efficacy during paediatric CPR provided by HCPs and LRs. Ventilation represents an important aspect of good-quality CPR in children. The concept of initiating paediatric CPR with initial breaths, as stated in ERC guidelines 2021, is justifiable. Trained HCPs and LRs providing dispatcher-assisted CPR could deliver effective ventilation to paediatric mannequins. These findings can contribute to future research in this area and address identified knowledge gaps concerning resuscitation guidelines, given the unique practical application of simulation as a research tool.

Assessment of Medical Test Overuse and Its Impact on Pediatric Emergency Department Outcomes in Upper Respiratory Tract Infections in a University Hospital in Lithuania

Medical overuse poses potential risks to patients and contributes to increasing healthcare costs, pediatric emergency departments (PED) in particular. Often, upper respiratory tract infection (URTI) cases are viral-induced and self-limiting, and they do not require specific investigations or treatment. We conducted a retrospective study from 1 December 2021 to 31 January 2022, thereby aiming to identify the common tests and factors influencing specific diagnostic and treatment decisions for URTI in PED. In total, 307 (74.9%) URTI cases underwent complete blood count (CBC) tests, 312 (76.1%) were subjected to C-reactive protein (CRP) tests, and 110 (26.8%) received urinalysis tests. Patients with a longer duration of fever and a physician's suspicion of bacterial infection were more likely to receive CBC, CRP, and/or urinalysis tests (p < 0.05). Moreover, 75.1% of the cases were classified as viral URTIs, 9.8% were bacterial URTIs, and 15.1% were unspecified. Notably, 86 (20.1%) children received antibiotics and antibiotic prescription correlated with age, tonsillitis diagnosis, CRP values higher than 30 mg/L, and a CBC of p < 0.05. Patients triaged in the second or third categories were three times more likely to be observed for 24 h compared to patients with URTI and the fourth triage category (p < 0.05). This study highlights the need for interventions to improve the appropriateness of emergency service utilization, thereby emphasizing the importance of judicious decision making in managing pediatric URTIs.

Association Between Chest Compression Pause Duration and Survival After Pediatric In-Hospital Cardiac Arrest

BACKGROUND

The association between chest compression (CC) pause duration and pediatric in-hospital cardiac arrest survival outcomes is unknown. The American Heart Association has recommended minimizing pauses in CC in children to <10 seconds, without supportive evidence. We hypothesized that longer maximum CC pause durations are associated with worse survival and neurological outcomes.

METHODS

In this cohort study of index pediatric in-hospital cardiac arrests reported in pediRES-Q (Quality of Pediatric Resuscitation in a Multicenter Collaborative) from July of 2015 through December of 2021, we analyzed the association in 5-second increments of the longest CC pause duration for each event with survival and favorable neurological outcome (Pediatric Cerebral Performance Category ≤3 or no change from baseline). Secondary exposures included having any pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds per 2 minutes.

RESULTS

We identified 562 index in-hospital cardiac arrests (median [Q1, Q3] age 2.9 years [0.6, 10.0], 43% female, 13% shockable rhythm). Median length of the longest CC pause for each event was 29.8 seconds (11.5, 63.1). After adjustment for confounders, each 5-second increment in the longest CC pause duration was associated with a 3% lower relative risk of survival with favorable neurological outcome (adjusted risk ratio, 0.97 [95% CI, 0.95-0.99]; P=0.02). Longest CC pause duration was also associated with survival to hospital discharge (adjusted risk ratio, 0.98 [95% CI, 0.96-0.99]; P=0.01) and return of spontaneous circulation (adjusted risk ratio, 0.93 [95% CI, 0.91-0.94]; P<0.001). Secondary outcomes of any pause >10 seconds or >20 seconds and number of CC pauses >10 seconds and >20 seconds were each significantly associated with adjusted risk ratio of return of spontaneous circulation, but not survival or neurological outcomes.

CONCLUSIONS

Each 5-second increment in longest CC pause duration during pediatric in-hospital cardiac arrest was associated with lower chance of survival with favorable neurological outcome, survival to hospital discharge, and return of spontaneous circulation. Any CC pause >10 seconds or >20 seconds and number of pauses >10 seconds and >20 seconds were significantly associated with lower adjusted probability of return of spontaneous circulation, but not survival or neurological outcomes.

Cardiopulmonary Resuscitation: Clinical Updates and Perspectives

Cardiopulmonary resuscitation (CPR) stands as a cornerstone in emergency care, representing the crucial link between life and death for victims of cardiac arrest [...].

Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey)

Aim

Survey of treatment practices and adherence to pediatric status epilepticus (PSE) management guidelines in India.

Methods

This eSurvey was conducted over 35 days (15th October to 20th November 2023) and included questions related to hospital setting; antiseizure medications (ASMs); ancillary treatment; facilities available; etiology; and adherence to PSE management guidelines.

Results

A total of 170 respondents participated, majority of them were working in tertiary level hospitals (94.1%) as pediatric intensivists (56.5%) and pediatricians (19.4%), and were in clinical practice for 2-10 years (46.5%). Majority use intravenous (IV) midazolam and levetiracetam as first- and second-line ASMs (67.1 and 51.2%, respectively). In cases with refractory status epilepticus (RSE), the most commonly used ASM is midazolam infusion (92.4%). For super-refractory status epilepticus (SRSE), the commonly used third-line ASMs include midazolam infusion (34.1%), thiopentone infusion (26.5%), high dose phenobarbitone (18.2%), and ketamine infusion (15.3%). Overall, in cases with SRSE, 44.7% respondents use ketamine infusion, 42.5% use add-on oral topiramate, and 34.7% use high-dose phenobarbitone (1-3 mg/kg/hour) infusion. Most respondents targeted both clinical and EEG seizure control (48.8%). Ancillary treatment used for SRSE included IV pyridoxine (57.1%), methylprednisolone (45.3%), IVIG (42.4%), ketogenic diet (40.6%), and second-line immunomodulation (33.5%). Most common causes were febrile SE, viral encephalitis, and febrile illness-related epilepsy syndrome (60.6%, 52.4%, and 37.1%, respectively). Facilities available included pediatric intensive care units (PICU) (97.1%), mechanical ventilation (98.2%), pediatric neurologist (68.8%), MRI brain (86.5%), EEG (69.4%), and viral PCR (58.2%). The compliance with guidelines for timing of initiation of ASM ranged from 63.5 to 88.8%.

Conclusion

Intravenous midazolam bolus/es, levetiracetam, and midazolam infusion are commonly used first-, second-, and third-line ASMs, respectively. There were wide variations in use of ASMs for RSE and SRSE, ancillary treatment, and compliance to PSE management guidelines.

How to cite this article

Suthar R, Angurana SK, Nallasamy K, Bansal A, Muralidharan J. Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey). Indian J Crit Care Med 2024;28(5):504-510.