Outcome of infants requiring cardiopulmonary resuscitation before extracorporeal membrane oxygenation

Singapore Paediatric Resuscitation Guidelines 2016

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.

Evaluating the influence of ventilation and ventilation-compression synchronization on chest compression force and depth during simulated neonatal resuscitation

OBJECTIVES

To investigate the influence of ventilation and ventilation-compression synchronization on compression force and sternal displacement during simulated neonatal cardiopulmonary resuscitation (NCPR) on an infant manikin.

METHODS

Five Neonatal Resuscitation Program trained clinicians were recruited to perform simulated NCPR on an infant manikin using two-finger (TF) and two-thumb (TT) compression, with synchronous and asynchronous ventilation, as well as without ventilation. The sternal displacement and force were recorded and analyzed.

RESULTS

Synchronous ventilation and compression yielded sternal displacements and forces in the range of 22.8-32.4 mm and 15.0-29.8 N, respectively, while asynchronous ventilation and compression produced depths and forces in the range of 21.2-32.4 mm and 14.0-28.8 N, respectively.

CONCLUSIONS

Ventilation exerts a significant influence on sternal displacement and force during simulated NCPR, regardless of the compression method used. Ventilation-compression synchronization, however, is only significant during TF compression with lower compression forces measured during synchronous ventilation than in asynchronous ventilation. This occurs for two reasons: (i) the strong influence of ventilation forces on the lower magnitude compression forces produced during TF compression relative to TT compression and (ii) in asynchronous ventilation, compression and ventilation may occur simultaneously, with inflation and deflation providing an opposing force to the applied compression force.

Extracorporeal membrane oxygenation

ECMO is an important tool to provide oxygen delivery and carbon dioxide removal in addition to cardiac support for patients with intractable reversible respiratory or cardiovascular collapse unresponsive to conventional treatment. Even though ECMO can be a life-saving modality, it is expensive and labor-intensive and carries a significant complication risk. Early recognition and prompt referral of patients who may benefit from ECMO in addition to careful patient selection, continuous communication between ECMO centers and their referral base, and meticulous care can improve the outcome of these critically ill patients who previously had no chance of survival.

Successful extracorporeal life support in cardiac arrest with recurrent ventricular fibrillation unresponsive to standard cardiopulmonary resuscitation

Extracorporeal life support has been used as an extension of conventional cardiopulmonary resuscitation (CPR). However, the appropriate indications for extracorporeal CPR (ECPR) including the duration of CPR are unknown. We present a case of a male, 37-year-old out-of-hospital cardiac arrest patient who received prolonged CPR followed by ECPR. Despite advanced cardiac life support, he did not regain a sustained spontaneous circulation and had recurrent ventricular fibrillation (VF) during the prolonged CPR. VF was unresponsive to CPR, defibrillation, adrenaline (epinephrine), and antiarrhythmics. The CPR time before ECPR was approximately 2h. During extracorporeal life support, the VF did not recur and percutaneous coronary angioplasty was achieved. Ultimately, the patient was discharged without neurological complications. Although cardiac arrest occurred out-of-hospital and CPR was performed for a long time, a patient might be a candidate for ECPR if perfusing rhythms are restored transiently but not successfully maintained due to recurrent VF. ECPR may be used for VF unresponsive to standard CPR techniques.

A history of pediatric critical care medicine

Critical care medicine developed out of other subspecialties' need to provide care for their most critically ill patients. Advanced technologies, the understanding of the pathophysiology of critical illness, and the development of the multidisciplinary team have made this care possible. Pediatric critical care medicine emerged in the 1960s and has expanded dramatically since then. The field has made major advances in the areas of lung injury, sepsis, traumatic brain injury, and postoperative care. We review here the evolution of modern pediatric critical care medicine from its roots in general pediatric and cardiac surgery, adult respiratory care medicine, neonatology, and pediatric anesthesiology to its current state as a unique discipline.

Duration of Cardiopulmonary Resuscitation before Extracorporeal Rescue: How Long Is Not Long Enough?

Despite the extensive resources required, extracorporeal cardiopulmonary resuscitation (ECPR) has been recognized as an extension of traditional CPR. The reported duration of CPR before ECPR initiation is similar between survivors and nonsurvivors, but the duration of CPR that results in futility of care is unknown. We report two cases of prolonged CPR followed by ECPR resulting in acceptable neurologic outcomes. Ventricular tachycardia developed in a 4-year-old with myocarditis, resulting in a cardiac arrest requiring CPR for 176 minutes before initiation of extracorporeal membrane oxygenation (ECMO). The patient required ECMO for 9 days. He survived neurologically normal. A ventricular arrhythmia developed in a newborn after an arterial switch procedure, leading to cardiac arrest requiring CPR for 97 minutes before ECMO, which lasted for 11 days. Hydrocephalus developed, but the patient is progressing developmentally. The upper limit of CPR duration before ECPR resulting in acceptable neurological outcomes is unknown. Many clinical and biochemical factors are potential predictors of appropriate ECPR utility. The Extracorporeal Life Support Organization registry is a plausible forum to collect data regarding ECPR. We suggest that possible predictive variables be collected. Until then, practitioners must rely on experience and judgment regarding the value of ECPR in children.

A wet-primed extracorporeal membrane oxygenation circuit with hollow-fiber membrane oxygenator maintains adequate function for use during cardiopulmonary resuscitation after 2 weeks on standby*

OBJECTIVE

To assess the durability of wet-preprimed extracorporeal membrane oxygenation (ECMO) circuits for potential use in resuscitation after a 2-wk period of storage.

DESIGN

Experimental laboratory study.

SETTING

Tertiary care pediatric cardiac intensive care unit.

SUBJECTS

None.

INTERVENTIONS AND MEASUREMENTS

14 ECMO circuits (polyvinyl chloride and super-Tygon tubing with hollow-fiber oxygenator, Medos Hilite 800LT) were primed with crystalloid under sterile conditions and stored for 0 (control, n = 4), 7 (n = 5) and 14 (n = 5) days and maintained at 8 degrees C on pump at 10 rpm and gas flow at 0.2 L/min. Daily samples were inspected for plasticizers by means of high-performance liquid chromatography and for microorganisms by culture and polymerase chain reaction techniques. After storage, the oxygenators were primed with red blood cells (hemoglobin, 12 g/dL) and tested in vitro with a deoxygenator according to Association for Advancement of Medical Instrumentation standards. Oxygen and CO(2) transfer rates were calculated by standard formulae at maximum blood flow (800 mL/min) and maximum sweep gas flow (1.6 L/min).

MAIN RESULTS

Oxygen transfer was linearly related to venous oxygen saturation, increasing by 11 mL/min for each 10% decrease in venous oxygen saturation. Estimated oxygen transfer at venous oxygen saturation of 60% was 45.8 mL/min (95% confidence interval [CI], 43.5-48.1) for controls, 51.0 mL/min (95% CI, 48.9-53.2) for 7-day oxygenators, and 49.0 mL/min (95% CI, 47.8-50.1) for 14-day oxygenators. CO(2) transfer declined to 29.2 mL/min at 14 days of storage, a mean fall of 11.5 mL/min (95% CI, 4.2-18.7) in comparison with 7-day storage. All circuits were free from microbes/microbial DNA. Plasticizer levels fell below the lower limit of detection (0.003 microg/mL) at 7 and 14 days.

CONCLUSIONS

A wet-preprimed ECMO circuit with hollow-fiber membrane oxygenator can be stored for up to 2 wks with adequately preserved function if prepared appropriately. These data may improve safe access to rapid-response ECMO support.

Neonatal and pediatric extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation provides an external circulation for the critically ill patient with components capable of supporting the cardiorespiratory system while the patient's innate organs recover from the primary insult. This therapy is often used in children with relatively well-elucidated indications. Although initially used in the setting of neonatal respiratory failure, the use of extracorporeal membrane oxygenation for pediatric respiratory and cardiac indications is not uncommon. The complications and the outcomes of extracorporeal membrane oxygenation compare favorably with other forms of conventional therapy.

Long-term follow-up of pediatric cardiac patients requiring mechanical circulatory support

BACKGROUND

The present study examines the long-term outcome of pediatric patients with cardiac disease who required mechanical circulatory support with extracorporeal membrane oxygenation or ventricular assist devices.

METHODS

Telephone interviews and questionnaires were administered to parents and physicians of pediatric cardiac patients who were in-hospital survivors after requiring mechanical circulatory support, with either extracorporeal membrane oxygenation or ventricular assist devices. Data was collected regarding these patients' general health, cardiac status, and neurologic outcome, and compared between the two modes of support.

RESULTS

Follow-up was available for 26 patients supported with extracorporeal membrane oxygenation (25 survivors, 96%) and 11 patients supported with ventricular assist devices (10 survivors, 91%); median follow-up 42 months, 11 to 92 months). More than 80% of survivors were in New York Heart Association class I or II. Of 31 patients for whom neurologic assessment data was available, moderate to severe neurologic impairment was more common for extracorporeal membrane oxygenation supported patients [13 of 21, 59%) than for ventricular assist device supported patients (2 of 10, 20% p = 0.03). Neurologic impairment was associated with small patient size and the use of circulatory arrest during cardiac surgical repair, but was not associated with in-hospital neurologic complications, carotid cannulation, or presupport cardiac arrest.

CONCLUSIONS

The long-term survival and cardiac functional status of pediatric cardiac patients requiring mechanical circulatory support is favorable. Extracorporeal membrane oxygenation supported patients demonstrate higher rates of neurologic impairment than patients supported with ventricular assist devices. Poor neurologic outcomes are associated with institution of support in younger patients with more complex congenital heart disease.

Extracorporeal membrane oxygenation discontinuation despite technically successful reoperation: A case report

Death remains a probable outcome of pediatric cardiac extracorporeal membrane oxygenation (ECMO) despite increasing efforts to improve the results. On venoarterial ECMO, in an obviously hopeless situation, the decision to withdraw a life supporting measure resulting in the sudden death of a child places a heavy burden on the team. After valvulotomy of critical aortic stenosis in a prenatally diagnosed term neonate, ECMO had to be installed during postoperative resuscitation. Despite technically successful homograft implantation while on ECMO complicated by postoperative bleeding, advancing multiorgan failure resulted in ECMO withdrawal. As shown in this case report, exact termination criteria are lacking but are necessary to prevent increasing team and resource related conflicts in pediatric cardiac ECMO.