Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Current Practices and Safety of Medication Use During Pediatric Rapid Sequence Intubation

OBJECTIVES

This study aimed to characterize medication-related practices during and immediately -following rapid sequence intubation (RSI) in pediatric care units across the United States and to evaluate adverse drug events.

METHODS

This was a multicenter, observational study of medication practices surrounding intubation in pediatric and neonatal intensive care unit (NICU) and emergency department patients across the United States.

RESULTS

A total of 172 patients from 13 geographically diverse institutions were included. Overall, 24%, 69%, and 50% received preinduction, induction, and neuromuscular blockade, respectively. Induction and neuromuscular blocking agent (NMBA) use was low in NICU patients (52% and 23%, respectively), whereas nearly all patients intubated outside of the NICU received both (98% and 95%, respectively). NICU patients who received RSI medications were older and weighed more. Despite infrequent use of atropine (21%), only 3 patients developed bradycardia after RSI. Of the 119 patients who received an induction agent, fentanyl (67%) and midazolam (34%) were administered most frequently. Hypotension and hypertension occurred in 23% and 24% of patients, respectively, but were not associated with a single induction agent. Etomidate use was low and not associated with development of adrenal insufficiency. Rocuronium was the most used NMBA (78%). Succinylcholine use was low (11%) and administered despite hyperkalemia in 2 patients. Postintubation sedation and analgesia were not used or inadequate based on timing of initiation in many patients who received a non-depolarizing NMBA.

CONCLUSIONS

Medication practices surrounding pediatric RSI vary across the United States and may be influenced by patient location, age, and weight.

Evaluation of non-thyroidal illness syndrome in shock patients admitted to pediatric intensive care unit in a developing country

During critical illness, children my experience various changes in their thyroid hormone levels. Such changes are termed non-thyroidal illness syndrome (NTI). The extent of change correlates with the severity of the illness and its outcomes in critically ill patients. This study aimed to investigate the correlation between the severity of shock and thyroid hormone derangement. This prospective observational study included forty patients aged one month to five years who were admitted to the pediatric intensive care unit (PICU) with shock. Thyroid function tests were conducted on admission, after shock reversal, and five days later. NTI patterns were observed in 70% of patients. The PIM2 score showed a significant negative correlation with T3 (r =  - 0.353, p = 0.026) and FT3 levels on admission (r =  - 0.417, p = 0.007). Furthermore, after shock reversal, the PIM2 score continued to exhibit significant negative correlations with T4 (r =  - 0.444, p = 0.004), T3 (r =  - 0.329, p = 0.038), FT3 (r =  - 0.355, p = 0.025), and FT4 levels (r =  - 0.379, p = 0.016).    Conclusion: This study underscores the high prevalence of NTI in PICU shock patients and suggests monitoring thyroid hormone levels for outcome prediction and treatment guidance. Further research is needed to optimize NTI management in critically ill children. What is Known: • Non-thyroidal illness syndrome (NTIS) is a condition observed in critically ill patients. • There has been limited research on NTI in children, and existing studies have generated conflicting results regarding the relationship between thyroid hormones and clinical outcomes in cases of sepsis and septic shock. What is New: • The study has revealed dynamic changes in free triiodothyronine (FT3) levels during the process of shock reversal and recovery in children who experienced shock. • A significant negative correlation was found between the Pediatric Index of Mortality 2 (PIM2) score and several thyroid hormone levels, including FT3 on admission and T4, FT3, and FT4 on shock reversal.

Rediscover the predictive capacity of B-type natriuretic peptide applied to neonatal supraventricular tachycardia

BACKGROUND

Supraventricular tachycardia (SVT) is one of the most common non-benign arrhythmias in neonates, potentially leading to cardiac decompensation. This study investigated the early risk factors of acute heart failure (AHF) secondary to SVT in neonates, and explored their value in guiding the selection of effective anti-arrhythmic treatment.

METHODS

A total of 43 newborns diagnosed with and treated for SVT between January 2017 and December 2022 were analyzed. According to the presence of AHF after restoring sinus rhythm in newborns with SVT, they were divided into SVT with AHF group and SVT without AHF group. Clinical data and anti-arrhythmic therapies were analyzed. Risk factors of AHF secondary to SVT in neonates were determined using logistic regression. The cut-off value for predictors of AHF secondary to SVT and demanding of a second-line anti-arrhythmic treatment was determined through receiver operating characteristic (ROC) analysis.

RESULTS

Time to initial control of tachycardia > 24 h, hyperkalemia, anemia, and plasma B-type natriuretic peptide (BNP) were identified as risk factors of AHF secondary to SVT in neonates. BNP exhibited AUC of 0.80 in predicting AHF, and BNP > 2460.5pg/ml (OR 2.28, 95% CI 1.27 ~ 45.39, P = 0.03) was an independent predictor, yielding sensitivity of 70.6% and specificity of 84.6%. Neonates with BNP > 2460.5pg/ml (37.5% versus 7.4%, P = 0.04) had a higher demand for a second line anti-arrhythmic treatment to terminate SVT, with sensitivity and specificity for BNP in predicting at 75.0%, 71.4%, respectively.

CONCLUSIONS

BNP could be used to predict an incident of AHF secondary to SVT and a demand of second-line anti-arrhythmic treatment to promptly terminate SVT and prevent decompensation in neonates.

Comparison of paediatric basic life support guidelines endorsed by member councils of Resuscitation Council of Asia

Background

Paediatric cardiac arrest outcomes, especially for infants, remain poor. Due to different training, resource differences, and historical reasons, paediatric cardiac arrest algorithms for various Asia countries vary. While there has been a common basic life support algorithm for adults by the Resuscitation Council of Asia (RCA), there is no common RCA algorithm for paediatric life support.We aimed to review published paediatric life support guidelines from different Asian resuscitation councils.

Methods

Pubmed and Google Scholar search were performed for published paediatric basic and advanced life support guidelines from January 2015 to June 2023. Paediatric representatives from the Resuscitation Council of Asia were sought and contacted to provide input from September 2022 till June 2023.

Results

While most of the components of published paediatric life support algorithms of Asian countries are similar, there are notable variations in terms of age criteria for recommended use of adult basic life support algorithms in the paediatric population less than 18 years old, recommended paediatric chest compression depth targets, ventilation rates post-advanced airway intra-arrest, and first defibrillation dose for shockable rhythms in paediatric cardiac arrest.

Conclusion

This was an overview and mapping of published Asian paediatric resuscitation algorithms. It highlights similarities across paediatric life support guidelines in Asian countries. There were some differences in components of paediatric life support which highlight important knowledge gaps in paediatric resuscitation science. The minor differences in the paediatric life support guidelines endorsed by the member councils may provide a framework for prioritising resuscitation research and highlight knowledge gaps in paediatric resuscitation.

Cardiac arrest and cardiopulmonary resuscitation in pediatric patients with cardiac disease: a narrative review

Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize the current recommendations, provide un update of current literature, and highlight knowledge gaps to guide research efforts. We specifically reviewed current knowledge on resuscitation strategies for high-risk categories of patients including patients with single-ventricle physiology, right-sided lesions, right ventricle restrictive physiology, left-sided lesions, myocarditis, cardiomyopathy, pulmonary arterial hypertension, and arrhythmias. Cardiac arrest occurs in about 1% of hospitalized children with cardiac disease, and in 5% of those admitted to an intensive care unit. Mortality after cardiac arrest in this population remains high, ranging from 30 to 65%. The neurologic outcome varies widely among studies, with a favorable neurologic outcome at discharge observed in 64%-95% of the survivors. Risk factors for cardiac arrest and associated mortality include younger age, lower weight, prematurity, genetic syndrome, single-ventricle physiology, arrhythmias, pulmonary arterial hypertension, comorbidities, mechanical ventilation preceding cardiac arrest, surgical complexity, higher vasoactive-inotropic score, and factors related to resources and institutional characteristics. Recent data suggest that Extracorporeal membrane oxygenation CPR (ECPR) may be a valid strategy in centers with expertise. Overall, knowledge on resuscitation strategies based on physiology remains limited, with a crucial need for further research in this field. Collaborative and interprofessional studies are highly needed to improve care and outcomes for this high-risk population. What is Known: • Children with cardiac disease are at high risk of cardiac arrest, and cardiopulmonary resuscitation may be challenging due to unique characteristics and different physiologies. • Mortality after cardiac arrest remains high and neurologic outcomes suboptimal. What is New: • We reviewed the unique resuscitation challenges, current knowledge, and recommendations for different cardiac physiologies. • We highlighted knowledge gaps to guide research efforts aimed to improve care and outcomes in this high-risk population.

A Survey of Academic Neonatologists on Neonatal Electrical Cardioversion and Defibrillation

OBJECTIVE

This study aimed to assess neonatologists' experience and comfort with neonatal electrical cardioversion or defibrillation (EC-D).

STUDY DESIGN

Electronic surveys were distributed to academic neonatologists affiliated with 12 Midwest academic hospitals. Neonatologists were asked about their residency training; years since completing residency; current certification/competency training in the Basic Life Support (BLS), Pediatric Advanced Life Support (PALS), Advanced Cardiovascular Life Support (ACLS), and Neonatal Resuscitation Program (NRP); experiences with EC-D; availability of a pediatric cardiologist; and their comfort levels with such procedures. Standard statistical tests evaluated comfort with EC-D.

RESULTS

Seventy-two out of 180 neonatologists responded to the survey (response rate = 40%). Of them, 98.6% (71), 54.2% (39), and 37.5% (27) maintained current NRP, BLS, and PALS trainings, respectively. Also, 73.6% (n = 53) reported having performed neonatal EC-D. Of those, 50.9% (n = 27) indicated feeling slightly to very uncomfortable performing EC-D. We report a lack of BLS certification being associated with a lack of comfort (odds ratio [OR]: 0.269, 95% confidence interval [CI]: [0.071, 0.936]), and a positive association between a pediatric cardiologist being present and being uncomfortable (OR: 3.722, 95% CI: [1.069, 14.059]). Those reporting greater volume and more recent experience with EC-D report more comfort.

CONCLUSION

Of neonatologists who performed EC-D, half of them reported being uncomfortable. BLS certification and experience are positively associated with comfort in performing EC-D. Simulations to increase training in EC-D should be offered regularly to academic neonatologists.

KEY POINTS

· Most neonatologists have performed EC-D, but many feel uncomfortable with performing EC-D.. · Many do not maintain current certification in BLS, PALS, or ACLS.. · Simulation training in EC-D will increase comfort with EC-D..

Who is the real team leader? Comparing leadership performance of the team leader and CPR Coach during simulated cardiac arrest

Purpose

To describe the leadership performance of team leaders and CPR Coaches, and to determine if there is a correlation between leadership scores and CPR performance during management of simulated pediatric cardiac arrest events.

Methods

This is a secondary analysis of data from a prior randomized controlled trial. We observed the performance of both team leaders and CPR coaches during the management of an 18-minute simulated cardiac arrest scenario which was run for 20 resuscitation teams comprised of CPR-certified professionals from four pediatric tertiary care centers. CPR Coaches were responsible for providing real-time verbal feedback of CPR performance to compressors. Two raters were trained to use the Behavioral Assessment Tool (BAT) to assess leadership performance of the team leader and CPR Coach. BAT scores of team leaders and CPR coaches were compared and linked with objective CPR performance.

Results

There was no significant difference between the BAT scores of team leaders and CPR coaches (median score 27/40 vs 28.8/40, p = 0.16). Higher BAT scores of team leaders were significantly associated with higher percentage of excellent CPR (r = 0.52, p = 0.02), while higher BAT scores of CPR coaches were significantly associated with higher chest compression fraction (r = 0.48, p = 0.03).

Conclusions

Both team leaders and CPR coaches have similarly high leadership performance during the management of simulated cardiac arrest. Leadership behaviors were associated with quality of CPR performance.Clinical Trial Registration: Registration ID: NCT02539238; https://www.clinicaltrials.gov.

Failure-to-rescue and mortality after emergent pediatric trauma laparotomy: How are the children doing?

INTRODUCTION

Emergent trauma laparotomy is associated with mortality rates of up to 40%. There is a paucity of data on the outcomes of emergent trauma laparotomies performed in the pediatric population. The aim of our study was to describe the outcomes, including mortality and FTR, among pediatric trauma patients undergoing emergent laparotomy and identify factors associated with failure-to-rescue (FTR).

METHODS

We performed a one-year (2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program dataset. All pediatric trauma patients (age <18 years) who underwent emergent laparotomy (laparotomy performed within 2 h of admission) were included. Outcome measures were major in-hospital complications, overall mortality, and failure-to-rescue (death after in-hospital major complication). Multivariate regression analysis was performed to identify factors independently associated with failure-to-rescue.

RESULTS

Among 120,553 pediatric trauma patients, 462 underwent emergent laparotomy. Mean age was 14±4 years, 76% of patients were male, 49% were White, and 50% had a penetrating mechanism of injury. Median ISS was 25 [13-36], Abdomen AIS was 3 [2-4], Chest AIS was 2 [1-3], and Head AIS was 2 [0-5]. The median time in ED was 33 [18-69] minutes, and median time to surgery was 49 [33-77] minutes. The most common operative procedures performed were splenectomy (26%), hepatorrhaphy (17%), enterectomy (14%), gastrorrhaphy (14%), and diaphragmatic repair (14%). Only 22% of patients were treated at an ACS Pediatric Level I trauma center. The most common major in-hospital complications were cardiac (9%), followed by infectious (7%) and respiratory (5%). Overall mortality was 21%, and mortality among those presenting with hypotension was 31%. Among those who developed in-hospital major complications, the failure-to-rescue rate was 31%. On multivariate analysis, age younger than 8 years, concomitant severe head injury, and receiving packed red blood cell transfusion within the first 24 h were independently associated with failure-to-rescue.

CONCLUSIONS

Our results show that emergent trauma laparotomies performed in the pediatric population are associated with high morbidity, mortality, and failure-to-rescue rates. Quality improvement programs may use our findings to improve patient outcomes, by increasing focus on avoiding hospital complications, and further refinement of resuscitation protocols.

LEVEL OF EVIDENCE

Level IV STUDY TYPE: Epidemiologic.

Trends in In-Hospital Cardiac Arrest and Mortality Among Children With Cardiac Disease in the Intensive Care Unit: A Systematic Review and Meta-analysis

IMPORTANCE

Data on trends in incidence and mortality for in-hospital cardiac arrest (IHCA) in children with cardiac disease in the intensive care unit (ICU) are lacking. Additionally, there is limited information on factors associated with IHCA and mortality in this population.

OBJECTIVE

To investigate incidence, trends, and factors associated with IHCA and mortality in children with cardiac disease in the ICU.

DATA SOURCES

A systematic review was conducted using PubMed, Web of Science, EMBASE, and CINAHL, from inception to September 2021.

STUDY SELECTION

Observational studies on IHCA in pediatric ICU patients with cardiac disease were selected (age cutoffs in studies varied from age ≤18 y to age ≤21 y).

DATA EXTRACTION AND SYNTHESIS

Quality of studies was assessed using the National Institutes of Health Quality Assessment Tools. Data on incidence, mortality, and factors associated with IHCA or mortality were extracted by 2 independent observers. Random-effects meta-analysis was used to compute pooled proportions and pooled ORs. Metaregression, adjusted for type of study and diagnostic category, was used to evaluate trends in incidence and mortality.

MAIN OUTCOMES AND MEASURES

Primary outcomes were incidence of IHCA and in-hospital mortality. Secondary outcomes were proportions of patients who underwent extracorporeal membrane oxygenation (ECMO) cardiopulmonary resuscitation (ECPR) and those who did not achieve return of spontaneous circulation (ROSC).

RESULTS

Of the 2574 studies identified, 25 were included in the systematic review (131 724 patients) and 18 in the meta-analysis. Five percent (95% CI, 4%-6%) of children with cardiac disease in the ICU experienced IHCA. The pooled in-hospital mortality among children who experienced IHCA was 51% (95% CI, 42%-59%). Thirty-nine percent (95% CI, 29%-51%) did not achieve ROSC; in centers with ECMO, 22% (95% CI, 14%-33%) underwent ECPR, whereas 22% (95% CI, 12%-38%) were unable to be resuscitated. Both incidence of IHCA and associated in-hospital mortality decreased significantly in the last 20 years (both P for trend < .001), whereas the proportion of patients not achieving ROSC did not significantly change (P for trend = .90). Neonatal age, prematurity, comorbidities, univentricular physiology, arrhythmias, prearrest mechanical ventilation or ECMO, and higher surgical complexity were associated with increased incidence of IHCA and mortality odds.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis found that 5% of children with cardiac disease in the ICU experienced IHCA. Decreasing trends in IHCA incidence and mortality suggest that education on preventive interventions, use of ECMO, and post-arrest care may have been effective; however, there remains a crucial need for developing resuscitation strategies specific to children with cardiac disease.

Pediatric Bradycardia Is Undertreated in the Prehospital Setting: A Retrospective Multi-Agency Analysis

BACKGROUND

Bradycardia is the most common terminal cardiac electrical activity in children, and early recognition and treatment is necessary to avoid cardiac arrest. Interventions such as oxygen, chest compressions, epinephrine, and atropine recommended by American Heart Association (AHA) Pediatric Advanced Life support (PALS) guidelines have been shown to improve outcomes (including higher survival rates) for inpatient pediatric patients with bradycardia. However, little is known about the epidemiology of pediatric prehospital bradycardia. We sought to investigate the incidence and management of pediatric bradycardia in the prehospital setting by emergency medical services (EMS).

METHODS

This was a retrospective study of 911 scene response prehospital encounters for patients ages 0-18 years in 2019 from the United States ESO Research Data Collaborative. We defined age-based bradycardia per the 2015 AHA PALS guidelines. We performed general descriptive statistics and a univariate analysis examining any PALS-recommended interventions in the presence of altered mental status, hypotension for age, and a first heart rate less than 60.

RESULTS

Of 7,422,710 encounters in the 2019 ESO Data Collaborative, 1,209 patients met inclusion criteria. Most (58.5%) were male, and the median age was 2 years (interquartile range 0-13 years). One-quarter (24.7%) of patients received fluids, and bag-valve mask ventilation was the most common airway intervention (12.1% of patients). Receipt of any PALS-recommended interventions was associated with age-adjusted hypotension (odds ratio (OR) 4.0, 95% confidence interval (CI) 3.9-5.4) and altered mental status (OR 15.5, 95% CI 10.7-22.3), but not a first heart rate less than 60 bpm (OR 0.9, 95% CI 0.6-1.1).

CONCLUSIONS

To our knowledge, this study is the first to examine the incidence and management of prehospital pediatric bradycardia. Incidence was rare, but adherence to PALS guidelines was variable. Further research and education are needed to ensure proper prehospital treatment of pediatric bradycardia.

Impact of Quality Improvement Bundle on Compliance with Resuscitation Guidelines during In-Hospital Cardiac Arrest in Children

Introduction

Various quality improvement (QI) interventions have been individually assessed for the quality of cardiopulmonary resuscitation (CPR). We aimed to assess the QI bundle (hands-on training and debriefing) for the quality of CPR in our children's hospital. We hypothesized that the QI bundle improves the quality of CPR in hospitalized children.

Methods

We initiated a QI bundle (hands-on training and debriefing) in August 2017. We conducted a before-after analysis comparing the CPR quality during July 2013-May 2017 (before) and January 2018-December 2020 (after). We collected data from the critical events logbook on CPR duration, chest compressions (CC) rate, ventilation rate (VR), the timing of first dose of epinephrine, blood pressure (BP), end-tidal CO₂ (EtCO₂), and vital signs monitoring during CPR. We performed univariate analysis and presented data as the median interquartile range (IQR) and in percentage as appropriate.

Results

We compared data from 58 CPR events versus 41 CPR events before and after QI bundle implementation, respectively. The median (IQR) CPR duration for the pre- and post-QI bundle was 5 (1-13) minutes and 3 minutes (1.25-10), and the timing of the first dose of epinephrine was 2 (1-2) minutes and 2 minutes (1-5), respectively. We observed an improvement in compliance with the CC rate (100-120 per minute) from 72% events before versus 100% events after QI bundle implementation (p=0.0009). Similarly, there was a decrease in CC interruptions and hyperventilation rates from 100% to 50% (p=0.016) and 100% vs. 63% (p=<0.0001) events before vs. after QI bundle implementation, respectively. We also observed improvement in BP monitoring from 36% before versus 60% after QI bundle (p=0.014).

Conclusion

Our QI bundle (hands-on training and debriefing) was associated with improved compliance with high-quality CPR in children.

Bronchodilator response after two methods of salbutamol nebulization in asthmatic children

Introduction

Salbutamol is used in bronchodilator response testing (BDRT), which is an important diagnostic tool in bronchial obstructive diseases. Most available studies compare the bronchodilator response of salbutamol administered with a pressurized metered-dose inhaler and salbutamol in a nebulization solution.

Aim

The spirometric evaluation of the bronchodilator response of two methods of salbutamol nebulization in asthmatic children.

Material and methods

A randomized, open, comparative study was conducted in which 132 children with partially controlled asthma and current bronchial obstruction determined by spirometry were enrolled. BDRT was conducted using salbutamol solution administered with either a continuous jet nebulizer (CON) or a breath-actuated jet nebulizer (BAN). The BAN group received half the dose of the drug compared to the CON group, i.e. 2.5 mg. Changes in FEV₁ and FEF25-75 after drug administration were calculated in relation to the baseline values.

Results

The change in FEV₁ after salbutamol administration was 16.9 ±9.7% in the BAN group and was statistically significantly higher than in the CON group (12.6 ±8.8%) (p = 0.026). The change in FEF25-75 was 37.7 ±23.2% in the BAN group and 32.7 ±25.5% in the CON group (p = 0.061). There were no statistically significant differences in the frequency of adverse events between the compared groups.

Conclusions

Salbutamol inhaled from BAN results in a better bronchodilator response than twice the nominal dose of this drug inhaled from CON, which is due to the absence of drug loss during the expiratory phase and therefore greater pulmonary deposition.

Prevention and Treatment of Cardiovascular Diseases with Plant Phytochemicals: A Review

Cardiovascular diseases (CVDs) are the world's leading killers, accounting for 30% deaths. According to the WHO report, CVDs kill 17.9 million people per year, and there will be 22.2 million deaths from CVD in 2030. The death rates rise as people get older. Regarding gender, the death rate of women by CVD (51%) is higher than that of men (42%). To decrease and prevent CVD, most people rely on traditional medicine originating from the plant (phytochemicals) in addition to or in preference to commercially available drugs to recover from their illness. The CVD therapy efficacy of 92 plants, including 15 terrestrial plants, is examined. Some medicinal plants well known to treat CVD are, Daucus carota, Nerium oleander, Amaranthus Viridis, Ginkgo biloba, Terminalia arjuna, Picrorhiza kurroa, Salvia miltiorrhiza, Tinospora cordifolia, Mucuna pruriens, Hydrocotyle asiatica, Bombax ceiba, and Andrographis paniculate. The active phytochemicals found in these plants are flavonoids, polyphenols, plant sterol, plant sulphur compounds, and terpenoids. A general flavonoid mechanism of action is to prevent low-density lipoprotein oxidation, which promotes vasodilatation. Plant sterols prevent CVD by decreasing cholesterol absorption in the blood. Plant sulphur compound also prevent CVD by activation of nuclear factor-erythroid factor 2-related factor 2 (Nrf2) and inhibition of cholesterol synthesis. Quinone decreases the risk of CVD by increasing ATP production in mitochondria while terpenoids by decreasing atherosclerotic lesion in the aortic valve. Although several physiologically active compounds with recognized biological effects have been found in various plants because of the increased prevalence of CVD, appropriate CVD prevention and treatment measures are required. More research is needed to understand the mechanism and specific plants' phytochemicals responsible for treating CVD.

Pediatric Cardiac Arrest Outcomes in the United States: A Nationwide Database Cohort Study

Background

Knowledge about the causes and outcomes of pediatric cardiac arrest in the emergency department is limited. The aim of our study was to evaluate the characteristics and outcomes of pediatric cardiac arrest in the emergency department (EDCA) and inpatient (IPCA) settings in the United States using a large database designed to provide nationwide estimates.

Methods

We performed a retrospective cohort study using the Nationwide Emergency Department Sample (NEDS), a database that includes both ED and inpatient encounters. The NEDS was analyzed for episodes of cardiac arrest between 2016-2018 in patients aged ≤18 years. Patients with cardiac arrest were identified using the International Classification of Diseases, 10th revision codes.

Results

A total of 15,348 pediatric cardiac arrest events with cardiopulmonary resuscitation were recorded, of which 13,239 had EDCA and 2,109 had IPCA. A lower survival rate of 19% was observed for EDCA compared to 40.4% for IPCA. While more than half of the EDCA events had no associated diagnoses, trauma (15.6%), respiratory failure (5%), asphyxiation (2.7%), acidosis (2.4%), and ventricular arrhythmia (1.4%) were associated with the remaining events. In comparison, the most frequently associated diagnoses for IPCA were respiratory failure (75.8%), acidosis (43.9%), acute kidney injury (27.2%), trauma (27.1%), and sepsis (22.5%). 

Conclusions

Survival rates for EDCA were less than half of that for IPCA. The low survival rates along with the distinctive characteristics of EDCA events suggest the need for further research in this area to identify remediable factors and improve survival.

Adherence to a Pediatric Continuous Infusion Propofol Policy for Sedation in Mechanically Ventilated Patients: Opportunities for Change and Improvement

OBJECTIVE

To evaluate adherence to an institutional continuous infusion propofol policy for sedation in mechanically ventilated patients, investigate the rate of propofol-related infusion syndrome (PRIS), and explore areas of improvement to enhance policy compliance and safety.

METHODS

This was a single center, retrospective chart review of patients admitted to a pediatric or cardiac intensive care unit within a large free-standing quaternary care pediatric hospital who received continuous propofol for non-procedural continuous sedation for at least 6 hours between 2014 and 2019. Propofol exposure (dose and duration), laboratory data, and hemodynamic outcomes of patients were evaluated.

RESULTS

A total of 104 patients (108 admissions and 133 treatment courses) met inclusion criteria. Policy adherence to propofol dosing and duration limitations were 70% (93/133 courses) and 68% (91/133 courses), respectively. Adherence to all elements of laboratory and hemodynamic monitoring was 23%. Hypotension and bradycardia were common among patients during propofol treatment courses. Except for hypertriglyceridemia, no significant difference in specific laboratory values were detected between patients exposed to greater than 66 mcg/kg/min (4 mg/kg/hr), compared with those exposed to less than 66 mcg/kg/min of propofol. Patients receiving therapy for longer than 48 hours had the highest rates of laboratory values associated with PRIS. No patient in the study cohort met full criteria for PRIS.

CONCLUSIONS

Adherence to elements of an institutional propofol policy was variable. Improvements in policy adherence may be enhanced by updating policy features, leveraging the electronic medical record order-set, and gaining consensus among key stakeholders.

Belhassen Tachycardia in a Pediatric Patient: A Simulation for Pediatric Emergency Medicine Fellows

Ventricular tachycardia in pediatric emergency department patients is a high-risk, low-frequency event well suited for education through simulation. This technical report describes a simulation-based curriculum for Pediatric Emergency Medicine fellows and senior residents involving the evaluation and management of a 10-year-old female presenting with palpitations who is ultimately diagnosed with Belhassen tachycardia. The curriculum highlights the features that differentiate Belhassen tachycardia (idiopathic left posterior fascicular ventricular tachycardia) from supraventricular or other tachycardias, building upon foundational pediatric resuscitation skills and Pediatric Advanced Life Support (PALS) algorithms for advanced learners.

Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial

IMPORTANCE

Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes.

OBJECTIVE

To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings.

DESIGN, SETTING, AND PARTICIPANTS

A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021).

INTERVENTION

During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest.

MAIN OUTCOMES AND MEASURES

The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge.

RESULTS

Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02837497.

Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis

OBJECTIVES

The ideal crystalloid fluid bolus therapy for fluid resuscitation in children remains unclear, but pediatric data are limited. Administration of 0.9% saline has been associated with hyperchloremic metabolic acidosis and acute kidney injury. The primary objective of this systematic review was to compare the effect of balanced versus unbalanced fluid bolus therapy on the mean change in serum bicarbonate or pH within 24 hours in critically ill children.

DATA SOURCES

We searched MEDLINE including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, CENTRAL Trials Registry of the Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform.

STUDY SELECTION

Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guidelines, we retrieved all controlled trials and observational cohort studies comparing balanced and unbalanced resuscitative fluids in critically ill children. The primary outcome was the change in serum bicarbonate or blood pH. Secondary outcomes included the prevalence of hyperchloremia, acute kidney injury, renal replacement therapy, and mortality.

DATA EXTRACTION

Study screening, inclusion, data extraction, and risk of bias assessments were performed independently by two authors.

DATA SYNTHESIS

Among 481 references identified, 13 met inclusion criteria. In the meta-analysis of three randomized controlled trials with a population of 162 patients, we found a greater mean change in serum bicarbonate level (pooled estimate 1.60 mmol/L; 95% CI, 0.04-3.16; p = 0.04) and pH level (pooled mean difference 0.03; 95% CI, 0.00-0.06; p = 0.03) after 4-12 hours of rehydration with balanced versus unbalanced fluids. No differences were found in chloride serum level, acute kidney injury, renal replacement therapy, or mortality.

CONCLUSIONS

Our systematic review found some evidence of improvement in blood pH and bicarbonate values in critically ill children after 4-12 hours of fluid bolus therapy with balanced fluid compared with the unbalanced fluid. However, a randomized controlled trial is needed to establish whether these findings have an impact on clinical outcomes before recommendations can be generated.

Know the Code: Medications for Resuscitation in Neonates

Resuscitations in the delivery room or the nursery cause significant stress for caregivers. Diligent preparation will improve the efficacy and safety of life-saving interventions and increase staff comfort. When establishment of an airway and delivery of positive pressure ventilation and chest compressions fail to result in return of spontaneous circulation, pharmacotherapeutic interventions should be considered. Epinephrine is first-line pharmacotherapy for severe bradycardia or cardiac arrest, increasing coronary arterial pressure and blood flow during chest compressions. Despite limited data regarding dosing and efficacy, the first dose of epinephrine may be delivered through the endotracheal tube during attainment of venous access (preferably a low-lying umbilical venous catheter in the delivery room). Intravenous dosing is preferred, and any facility caring for newborns must ensure optimized logistics including readily available dosing guidance and optimal flush volumes. After provision of epinephrine, additional medications may be considered, especially for resuscitations occurring outside of the immediate perinatal period, including normal saline, glucose, adenosine, atropine, and calcium. Clinicians must understand the indications, dosing, and monitoring parameters for these medications and ensure rapid availability for resuscitation. Every second truly counts in a neonatal resuscitation, and optimal understanding and preparation will ensure delivery of pharmacotherapy to optimize both patient outcomes and staff comfort.

Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review

Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.

Excessive Oxygen Supplementation in the First Day of Mechanical Ventilation Is Associated With Multiple Organ Dysfunction and Death in Critically Ill Children

OBJECTIVES

To determine if greater cumulative exposure to oxygen despite adequate oxygenation over the first 24 hours of mechanical ventilation is associated with multiple organ dysfunction syndrome at 7 days and inhospital mortality in critically ill children.

DESIGN

Retrospective, observational cohort study.

SETTING

Two urban, academic PICUs.

PATIENTS

Patients less than 18 years old who required mechanical ventilation within 3 days of admission between 2010 and 2018 (Lurie Children's Hospital) or 2010 and 2016 (Comer Children's Hospital).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 5,406 mechanically ventilated patients, of which 960 (17.8%) had multiple organ dysfunction syndrome on day 7 of admission and 319 died (5.9%) during their hospitalization. Cumulative exposure to greater amounts of supplemental oxygen, while peripheral oxygen saturation was 95% or more during the first 24 hours of mechanical ventilation was independently associated with an increased risk of both multiple organ dysfunction syndrome on day 7 and inhospital mortality after adjusting for confounders. Patients in the highest quartile of cumulative oxygen exposure had an increased odds of multiple organ dysfunction syndrome on day 7 (adjusted odds ratio, 3.9; 95% CI, 2.7-5.9) and inhospital mortality (adjusted odds ratio, 1.7; 95% CI, 1.1-2.9), when compared with those in the lowest quartile of cumulative oxygen exposure after adjusting for age, presence of multiple organ dysfunction syndrome on day 1 of mechanical ventilation, immunocompromised state, and study site.

CONCLUSIONS

Greater cumulative exposure to excess supplemental oxygen in the first 24 hours of mechanical ventilation is independently associated with an increased risk of multiple organ dysfunction syndrome on day 7 of admission and inhospital mortality in critically ill children.

Incidence of Bradycardia and the Use of Atropine in Pediatric Rapid Sequence Intubation in the Emergency Department

OBJECTIVE

Bradycardia during rapid sequence intubation (RSI) is an uncommon but serious adverse effect encountered in pediatric intubations. Atropine has historically been used in the pediatric population as RSI premedication to prevent bradycardia, especially when using succinylcholine as an induction agent. The objective of this analysis was to identify the incidence of bradycardia with or without atropine use.

METHODS

This single-center, retrospective, observational case series reviewed pediatric patients up to 18 years old requiring intubation from January 1, 2015, to December 31, 2018. Bradycardia was determined by analyzing heart rates associated with time during and up to 5 minutes after intubation.

RESULTS

A total of 62 patients were included. Three (4.8%) patients experienced a bradycardic event during intubation. A total of 15 (24.2%) patients received atropine for pretreatment of RSI. Incidence of bradycardia was similar between those who received atropine and those who did not. An increasing trend in atropine use was shown throughout the assessment period, yet only 18 (29%) patients met criteria for atropine pretreatment based on the 2015 Pediatric Advanced Life Support guideline recommendations for RSI.

CONCLUSION

Bradycardia incidence was low in pediatric patients undergoing RSI in our emergency department. Use of atropine or succinylcholine did not affect the incidence of bradycardia during pediatric intubation over this study period. Our results show a low incidence of bradycardia and support the 2015 Pediatric Advanced Life Support Guideline recommendation of limiting the use of atropine premedication in pediatric intubations.

Treatment-Resistant Wide-Complex Tachycardia in a Three-Year-Old Girl

Wide-complex, monomorphic tachycardias represent a range of tachyarrhythmias. Such patients can present asymptomatically and hemodynamically stable, while others are in shock. The etiology of the rhythm can be difficult to determine in the emergency department, and although electrocardiogram findings may be helpful, a workup after stabilization may be necessary to determine the cause. Treatment is therefore dependent on hemodynamic status and follows a stepwise approach, as initial therapies may be ineffective. We present the case of a three-year-old girl with wide-complex tachycardia which was exceedingly refractory to preliminary treatments and required trials of multiple treatment approaches to achieve conversion to normal sinus rhythm.

High dose of epinephrine does not improve survival of children with out-of-hospital cardiac arrest: Results from the French National Cardiac Arrest Registry

OBJECTIVES

The pediatric resuscitation guidelines recommend the use of 0. 01 mg kg^-1 epinephrine during a cardiac arrest; an epinephrine dose higher than that is not recommended. The first aim of this study was to determine the administration rate of high epinephrine dose during pediatric out-of-hospital cardiac arrest. The second aim was to compare the survival status in patients who received high or standard doses of epinephrine.

METHODS

This was a multicenter comparative post-hoc study conducted between January 2011 and July 2021 based on the French National Cardiac Arrest Registry data. All prepubescent (boys < 12 years old, girls < 10 years old) victims of an out-of-hospital cardiac arrest were included. To compare survival status and control bias, patients who received a high epinephrine dose were matched with those who received a standard epinephrine dose using propensity score matching.

RESULTS

The analysis included 755 patients; 400 (53%) received a high dose and 355 (47%) received a standard dose of epinephrine. The median dose (mg kg^-1) per bolus was higher in the high-dose group than that in the standard dose group (0.04 vs. 0.01 mg kg^-1, P < 0.001). Before matching, there was no between-group difference in the 30-day survival rate or survival status at hospital discharge. Matching yielded 288 pairs; there was no between-group difference in the 30-day survival rate or survival at hospital discharge (High dose, n = 5; standard dose, n = 12; Odds ratios: 2.40, 95% confidence interval: 0.85-6.81). Only 2 patients in the standard dose group had a good neurological outcome.

CONCLUSION

More than 50% of the patients did not receive the recommended epinephrine dose during resuscitation. There was no association between patients receiving a high dose or standard dose of epinephrine with the 30-day survival or survival status at hospital discharge. Collaboration across multiple cardiac arrest registries is needed to study the application of pediatric guidelines.

Endotracheal Administered Epinephrine Is Effective in Return of Spontaneous Circulation Within a Pediatric Swine Hypovolemic Cardiac Arrest Model

OBJECTIVE

Early administration of epinephrine increases the incidence of return of spontaneous circulation (ROSC) and improves outcomes among pediatric cardiac arrest victims. Rapid endotracheal (ET) intubation can facilitate early administration of epinephrine to pediatric victims. To date, no studies have evaluated the use of ET epinephrine in a pediatric hypovolemic cardiac arrest model to determine the incidence of ROSC.

METHODS

This prospective, experimental study evaluated the pharmacokinetics and/or incidence of ROSC following ET administered epinephrine and compared it to these experimental groups: intravenous (IV) administered epinephrine, cardiopulmonary resuscitation only (CPR), and CPR + defibrillation (CPR + Defib).

RESULTS

Endotracheal administered epinephrine, at the Pediatric Advanced Life Support (PALS) recommended dose, was not significantly different than IV administered epinephrine in maximum plasma concentrations, time to maximum plasma concentration, area under the curve, or ROSC, or mean plasma concentrations at various time points (P > 0.05). The odds of ROSC in the ET group were 2.4 times greater than the IV group. The onset to ROSC in the ET group was significantly shorter than the IV group (P < 0.0001).

CONCLUSIONS

These data support that ET epinephrine administration remains an alternative to IV administered epinephrine and faster at restoring ROSC among pediatric hypovolemic cardiac arrest victims in the acute setting when an endotracheal tube is present. Although further research is required to determine long-term outcomes of high-dose ET epinephrine administration, these data reinforce the therapeutic potential of ET administration of epinephrine to restore ROSC before IV access.

Resuscitation 2020: Proceedings From the NeoHeart 2020 International Conference

Resuscitation guidelines are developed and revised by medical societies throughout the world. These guidelines are increasingly based on evidence from preclinical and clinical research. The International Liaison Committee on Resuscitation reviews evidence for each resuscitation practice and provides summary consensus statements that inform resuscitation guideline committees. A similar process is used for different populations including neonatal, pediatric, and adult resuscitation. The NeoHeart 2020 Conference brought together experts in resuscitation to discuss recent evidence and guidelines for resuscitation practices. This review summarizes the main focus of discussion from this symposium.

Effect of topography and weather on delivery of automatic electrical defibrillator by drone for out-of-hospital cardiac arrest

Delivery of automatic electrical defibrillator (AED) by unmanned aerial vehicle (UAV) was suggested for out-of-hospital cardiac arrest (OHCA). The goal of this study is to assess the effect of topographic and weather conditions on call to AED attach time by UAV-AED. We included OHCA patients from 2013 to 2016 in Seoul, South Korea. We developed a UAV-AED flight simulator using topographic information of Seoul for Euclidean and topographic flight pathway including vertical flight to overcome high-rise structures. We used 4 kinds of UAV flight scenarios according to weather conditions or visibility. Primary outcome was emergency medical service (EMS) call to AED attach time. Secondary outcome was pre-arrival rate of UAV-AED before current EMS based AED delivery. Call to AED attach time in topographic pathway was 7.0 min in flight and control advanced UAV and 8.0 min in basic UAV model. Pre-arrival rate in Euclidean pathway was 38.0% and 16.3% for flight and control advanced UAV and basic UAV. Pre-arrival rate in the topographic pathway was 27.0% and 11.7%, respectively. UAV-AED topographic flight took longer call to AED attach time than Euclidean pathway. Pre-arrival rate of flight and control advanced UAV was decreased in topographic flight pathway compared to Euclidean pathway.

The skills of defibrillation practice and certified life-support training in the healthcare providers in Turkey

AIM OF THE STUDY

Successful cardiopulmonary resuscitation and early defibrillation are critical in survival after in- or out-of-hospital cardiopulmonary arrest. The scope of this multi-centre study is to (a) assess skills of paediatric healthcare providers (HCPs) concerning two domains: (1) recognising rhythm abnormalities and (2) the use of defibrillator devices, and (b) to evaluate the impact of certified basic-life-support (BLS) and advanced-life-support (ALS) training to offer solutions for quality of improvement in several paediatric emergency cares and intensive care settings of Turkey.

METHODS

This cross-sectional and multi-centre survey study included several paediatric emergency care and intensive care settings from different regions of Turkey.

RESULTS

A total of 716 HCPs participated in the study (physicians: 69.4%, healthcare staff: 30.6%). The median age was 29 (27-33) years. Certified BLS-ALS training was received in 61% (n = 303/497) of the physicians and 45.2% (n = 99/219) of the non-physician healthcare staff (P < .001). The length of professional experience had favourable outcome towards an increased self-confidence in the physicians (P < .01, P < .001). Both physicians and non-physician healthcare staff improved their theoretical knowledge in the practice of synchronised cardioversion defibrillation (P < .001, P < .001). Non-certified healthcare providers were less likely to manage the initial doses of synchronised cardioversion and defibrillation: the correct responses remained at 32.5% and 9.2% for synchronised cardioversion and 44.8% and 16.7% for defibrillation in the physicians and healthcare staff, respectively. The indications for defibrillation were correctly answered in the physicians who had acquired a certificate of BLS-ALS training (P = .047, P = .003).

CONCLUSIONS

The professional experience is significant in the correct use of a defibrillator and related procedures. Given the importance of early defibrillation in survival, the importance and proper use of defibrillators should be emphasised in Certified BLS-ALS programmes. Certified BLS-ALS programmes increase the level of knowledge and self-confidence towards synchronised cardioversion-defibrillation procedures.

Emergencies in obese patients: a narrative review

Obesity is associated to an increased risk of morbidity and mortality due to respiratory, cardiovascular, metabolic, and neoplastic diseases. The aim of this narrative review is to assess the physio-pathological characteristics of obese patients and how they influence the clinical approach during different emergency settings, including cardiopulmonary resuscitation. A literature search for published manuscripts regarding emergency and obesity across MEDLINE, EMBASE, and Cochrane Central was performed including records till January 1, 2021. Increasing incidence of obesity causes growth in emergency maneuvers dealing with airway management, vascular accesses, and drug treatment due to both pharmacokinetic and pharmacodynamic alterations. Furthermore, instrumental diagnostics and in/out-hospital transport may represent further pitfalls. Therefore, people with severe obesity may be seriously disadvantaged in emergency health care settings, and this condition is enhanced during the COVID-19 pandemic, when obesity was stated as one of the most frequent comorbidity. Emergency in critical obese patients turns out to be an intellectual, procedural, and technical challenge. Organization and anticipation based on the understanding of the physiopathology related to obesity are very important for the physician to be mentally and physically ready to face the associated issues.

NRP Versus PALS for Infants Outside the Delivery Room: Not If, but When?

BACKGROUND

Both the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines can be used for infants requiring cardiopulmonary resuscitation outside the delivery room. Each set of guidelines has supporting algorithms for resuscitation; however, there are no current recommendations for transitioning older infants outside the delivery room.

OBJECTIVE

To provide background information on the algorithms in the Neonatal Resuscitation Program and Pediatric Advanced Life Support guidelines and to discuss the role that nurses and advanced practice nurses play in advancing scientific research on resuscitation.

CONTENT COVERED

Summaries of both sets of guidelines, differences in practices, and recommendations for practice changes will be discussed.

DISCUSSION

Provider preference and unit practice determine which guidelines are used for infants outside the delivery room. Providers in pediatric intensive care units and pediatric cardiac intensive care units often use the Pediatric Advanced Life Support guidelines, whereas providers in neonatal intensive care units use the Neonatal Resuscitation Program guidelines for infants of the same age. The variation in resuscitation practices for infants outside the delivery room can negatively affect resuscitation outcomes.

Superiority of OxyMaskTM with less carbon dioxide rebreathing in children

Despite the growing importance of oxygen-delivery devices worldwide, there are only a few reports of physiological data on various oxygen masks in children. The possibility of carbon dioxide (CO₂) rebreathing has been a prevalent concern with the use of oxygen-delivery devices. OxyMask Kid^TM (Southmedic Inc. Canada; hereafter OxyMask) is expected to reduce CO₂ rebreathing even at low oxygen flow rates because of its structural features. Biological data using OxyMask in children have not been well investigated. Measured respiratory parameters of OxyMask with those of a simple oxygen mask in healthy children were compared. Ten subjects were enrolled, with a median age of 5.4 years. All subjects used both OxyMask and a simple oxygen mask. The fraction of inspiratory oxygen (F_IO₂), partial pressure of inspiratory CO₂ (P_ICO₂), and partial pressure of end-tidal CO₂ were measured using a sidestream gas-sampling monitor in all subjects. The oxygen flow rate was set at 1, 3, 5, and 10 L/min. F_IO₂ levels were higher with OxyMask than those with the simple oxygen mask at 3 L/min of oxygen. P_ICO₂ levels were significantly lower with OxyMask than those with the simple oxygen mask (1.5 mmHg vs. 3.7 mmHg at 1 L/min, P = 0.005; 1.0 mmHg vs. 2.7 mmHg at 3 L/min, P = 0.005, respectively), whereas P_ICO₂ levels were higher at low oxygen flow rates with both masks.Conclusion: Our results showed that higher F_IO₂ and less CO₂ rebreathing were achieved with OxyMask than those with a simple oxygen mask at low flow rates of oxygen in healthy children. What is Known: • OxyMask is expected to reduce carbon dioxide rebreathing even at low oxygen flow rates because of its structural features. • Efficacy has been demonstrated in experimental models and adult data, but clinical data on the use of the OxyMask in children are limited. What is New: • Higher fraction of inspiratory oxygen and lesser carbon dioxide rebreathing were achieved with OxyMask than with a simple oxygen mask at low flow rates of oxygen in healthy children.

Bradycardia Without Hypertension: Is It a Common Clinical Presentation of Ventriculoperitoneal Shunt Malfunction in Pediatric Patients?

BACKGROUND

Mechanical shunting of cerebrospinal fluid is an effective treatment for hydrocephalus. Some studies suggest that bradycardia without hypertension may also be observed in ventriculoperitoneal (VP) shunt malfunction; however, in our experience, this is not a common presenting sign.

OBJECTIVE

The aim of this study was to evaluate whether bradycardia without hypertension was a common sign in patients presenting to the pediatric emergency department (ED) with a VP shunt malfunction.

METHODS

A retrospective observational study, from May 2006 to April 2015, which included a random sample of children admitted to the ED with clinical features suggestive of possible VP shunt malfunction. Control patients were defined as those who arrived at our ED with suspected VP shunt malfunction that was later ruled out on further workup.

RESULTS

A total of 65 patients were included in this study. A significantly greater number of patients with a confirmed shunt pathology presented with vomiting (P = 0.01) and lethargy/apathy (P = 0.01). In the control group, a significantly greater number of patients presented with fever (P = 0.004) and seizures (P = 0.02). The number of patients presenting with bradycardia was not significantly different between the shunt pathology and control groups (P > 0.05).

CONCLUSIONS

Bradycardia is not a common presentation in patients with VP shunt malfunction. Bradycardia is often recognized as a significant sign; however, it is one of the last presenting signs. Educating patients about the early signs must be considered as part of the treatment for VP shunt malfunction.

Content Evidence for Validity of Time-to-Task Initiation: A Novel Measure of Learner Competence

INTRODUCTION

Educators require validated tools to assess learner competency in simulation-based mastery learning. We previously created a simulation to incorporate crisis resource management skills after a needs assessment of our pediatric residency program. We present the development of and content evidence for validity of a task list with time-to-task initiation designed to aid in rapid cycle deliberate practice (RCDP) debriefing and assessment of pediatrics resident learners.

METHODS

Five board-certified pediatricians developed the initial task list with 30 tasks. We used the Delphi technique to seek content evidence for validity of the initial task list using 17 board-certified pediatricians at 7 institutions across the United States. After finalizing the task list, we video recorded 3 pediatric experts performing the tasks in a simulation. We then used the Delphi technique to establish and to attain agreement on time-to-task initiation. We calculated Cronbach α coefficient to measure internal consistency of the expert responses. After finalizing the task list, we divided it into 3 stages with 5 separate cycles per stage to direct the educator in performance of RCDP debriefing.

RESULTS

The group reached 80% agreement after 2 Delphi rounds with a Cronbach α coefficient of 0.95. The resultant list included 25 tasks. The group subsequently achieved 80% agreement on the time-to-task initiation in 2 Delphi rounds.

CONCLUSIONS

We present content evidence for validity of a task list with associated time-to-task initiation for a simulation scenario that incorporates crisis resource management skills and is designed to aid educators in RCDP debriefing. This task list may decrease intereducator inconsistencies in delivery of RCDP for a common pediatric resuscitation scenario.

Use of an end-tidal carbon dioxide-guided algorithm during cardiopulmonary resuscitation improves short-term survival in paediatric swine

Aim

To evaluate an algorithm that uses an end-tidal carbon dioxide (ETCO₂) target of ≥ 30 torr to guide specific changes in chest compression rate and epinephrine administration during cardiopulmonary resuscitation (CPR) in paediatric swine.

Methods

Swine underwent asphyxial cardiac arrest followed by resuscitation with either standard or ETCO₂-guided algorithm CPR. The standard group received chest compressions at a rate of 100/min and epinephrine every 4 min during advanced life support consistent with the American Heart Association paediatric resuscitation guidelines. In the ETCO₂-guided algorithm group, chest compression rate was increased by 10 compressions/min for every minute that the ETCO₂ was < 30 torr, and the epinephrine administration interval was decreased to every 2 min if the ETCO₂ remained < 30 torr. Short-term survival and physiologic data during active resuscitation were compared.

Results

Short-term survival was significantly greater in the ETCO₂-guided algorithm CPR group than in the standard CPR group (16/28 [57.1%] versus 4/28 [14.3%]; p = 0.002). Additionally, the algorithm group had higher predicted mean ETCO₂, chest compression rate, diastolic and mean arterial pressure, and myocardial perfusion pressure throughout resuscitation. Swine in the algorithm group also exhibited significantly greater improvement in diastolic and mean arterial pressure and cerebral perfusion pressure after the first dose of epinephrine than did those in the standard group. Incidence of resuscitation-related injuries was similar in the two groups.

Conclusions

Use of a resuscitation algorithm with stepwise guidance for changes in the chest compression rate and epinephrine administration interval based on a goal ETCO₂ level improved survival and intra-arrest hemodynamics in this porcine cardiac arrest model.

Single Versus Double Anatomic Site Intraosseous Blood Transfusion in a Swine Model of Hemorrhagic Shock

BACKGROUND

Blood transfusion via single site intraosseous access is a critical modality when caring for a trauma victim that lacks intravascular access. Flow rates and potential clinical complications when utilizing two sites of intraosseous access are not well known.

MATERIALS AND METHODS

Anesthetized adult female Yorkshire swine (Sus scrofa; n = 48; 76.7 ± 1.75kg; range 66-90kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to treatment groups: single sited humerus, single sited sternum, dual sited humerus or dual sited humerus and sternum. Flow rates, hemolysis, physiologic measurements, biochemical variables, and pulmonary histologic inflammation and occlusion were contrasted between groups.

RESULTS

Dual sited intraosseous transfusion flow rates (128ml/min, 95% CI 123-132) were double the flow rates of single sites (65ml/min, 95% CI 60-70), P < .0001.Single sited humeral flow rates were greater than sternal flow rates, with respective averages of 74ml/min and 55ml/min, though not reaching statistical significance (P < 0.17). There was no significant elevation of plasma free hemoglobin in any group after transfusion as compared to baseline (P = 0.7). Groups did not significantly differ in vitals or biochemical variables. Most pulmonary specimens had some intraparenchymal fat embolism, however no animals had evidence of occlusive intra-arterial fat embolism.

CONCLUSIONS

Dual anatomic site, pressure bag driven, intraosseous blood transfusion approximately doubles flow rates without evidence of clinical complications or hemolysis. Further research using a survivability model is needed to characterize long-term complications from pressurized IO transfusions.

Hemodynamic monitoring and management of pediatric septic shock

Sepsis remains a major cause of morbidity and mortality among children worldwide. Furthermore, refractory septic shock and multiple organ dysfunction syndrome are the most critical groups which account for a high mortality rate in pediatric sepsis, and their clinical course often deteriorates rapidly. Resuscitation based on hemodynamics can provide objective values for identifying the severity of sepsis and monitoring the treatment response. Hemodynamics in sepsis can be divided into two groups: basic and advanced hemodynamic parameters. Previous therapeutic guidance of early-goal directed therapy (EGDT), which resuscitated based on the basic hemodynamics (central venous pressure and central venous oxygen saturation (ScvO2)) has lost its advantage compared with “usual care”. Optimization of advanced hemodynamics, such as cardiac output and systemic vascular resistance, has now been endorsed as better therapeutic guidance for sepsis. Despite this, there are still some important hemodynamics associated with prognosis. In this article, we summarize the common techniques for hemodynamic monitoring, list important hemodynamic parameters related to outcomes, and update evidence-based therapeutic recommendations for optimizing resuscitation in pediatric septic shock.

Hospital-based intervention is rarely needed for children with low-grade blunt abdominal solid organ injury: An analysis of the Trauma Quality Improvement Program registry

BACKGROUND

Children with low-grade blunt solid organ injury (SOI) have historically been admitted to an inpatient setting for monitoring, but the evidence supporting the necessity of this practice is lacking. The purpose of this study was to quantify the frequency and timing of intervention for hemorrhage and to describe hospital-based resource utilization for low-grade SOI in the absence of other major injuries (OMIs).

METHODS

A cohort of children (aged <16 years) with blunt American Association for the Surgery of Trauma grade 1 or 2 SOI from the American College of Surgeons Trauma Quality Improvement Program registry (2007-2017) was analyzed. Children were excluded if they had confounding factors associated with intervention for hemorrhage (comorbidities, OMIs, or extra-abdominal surgical procedures). Outcomes included frequency and timing of intervention (laparotomy, angiography, or transfusion) for hemorrhage, as well as hospital-based resource utilization.

RESULTS

A total of 1,019 children were identified with low-grade blunt SOI and no OMIs. Nine hundred eighty-six (96.8%) of these children were admitted to an inpatient unit. Admitted children with low-grade SOI had a median length-of-stay of 2 days and a 23.9% intensive care unit admission rate. Only 1.7% (n = 17) of patients with low-grade SOI underwent an intervention, with the median time to intervention being the first hospital day. No child who underwent angiography was transfused or had an abnormal initial ED shock index.

CONCLUSION

Children with low-grade SOI are routinely admitted to the hospital and often to the intensive care unit but rarely undergo hospital-based intervention. The most common intervention was angiography, with questionable indications in this cohort. These data question the need for inpatient admission for low-grade SOI and suggest that discharge from the emergency room may be safe. Prospective investigation into granular risk factors to identify the rare patient needing hospital-based intervention is needed, as is validation of the safety of ambulatory management.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

What are the care needs of families experiencing cardiac arrest?: A survivor and family led scoping review

AIM

The sudden and unexpected cardiac arrest of a family member can be a grief-filled and life-altering event. Every year many hundreds of thousands of families experience the cardiac arrest of a family member. However, care of the family during the cardiac arrest and afteris poorly understood and incompletely described. This review has been performed with persons with lived experience of cardiac arrest to describe, "What are the needs of families experiencing cardiac arrest?" from the moment of collapse until the outcome is known.

METHODS

This review was guided by specific methodological framework and reporting items (PRISMA-ScR) as well as best practices in patient and public involvement in research and reporting (GRIPP2). A search strategy was developed for eight online databases and a grey literature review. Two reviewers independently assessed all articles for inclusion and extracted relevant study information.

RESULTS

We included 47 articles examining the experience and care needs of families experiencing cardiac arrest of a family member. Forty one articles were analysed as six represented duplicate data. Ten family care need themes were identified across five domains. The domains and themes transcended cardiac arrest setting, aetiology, family-member age and family composition. The five domains were i) focus on the family member in cardiac arrest, ii) collaboration of the resuscitation team and family, iii) consideration of family context, iv) family post-resuscitation needs, and v) dedicated policies and procedures. We propose a conceptual model of family centred cardiac arrest.

CONCLUSION

Our review provides a comprehensive mapping and description of the experience of families and their care needs during the cardiac arrest of a family-member. Furthermore, our review was conducted with co-investigators and collaborators with lived experience of cardiac arrest (survivors and family members of survivors and non-survivors alike). The conceptual framework of family centred cardiac arrest care presented may aid resuscitation scientists and providers in adopting greater family centeredness to their work.

Pathophysiology and Treatment of Malignant Hyperthermia

Malignant hyperthermia (MH) is caused by a genetic disorder of the skeletal muscle that induces a hypermetabolic response when patients are exposed to a triggering agent such as volatile inhaled anesthetics or depolarizing neuromuscular blockers. Symptoms of MH include increased carbon dioxide production, hyperthermia, muscle rigidity, tachypnea, tachycardia, acidosis, hyperkalemia, and rhabdomyolysis. Common scenarios for triggering agents are those used are during surgery and rapid sequence intubation. Hypermetabolic symptoms have a rapid onset; hence, prompt recognition and treatment are vital to prevent morbidity and mortality. The first-line treatment agent for an MH response is dantrolene. Further treatment includes managing complications related to a hypermetabolic response such as hyperkalemia and arrhythmias. This review is focused on the recognition and treatment considerations of MH in the emergency department to optimize therapy and improve patient morbidity and mortality.

Time out! Pauses during advanced life support in high-fidelity simulation: A cross-sectional study

BACKGROUND

Prolonged preshock pauses are associated with negative effects on patient outcomes and survival. A greater understanding of these pauses may help to improve the quality of advanced life support (ALS) and clinical outcomes.

OBJECTIVE

The objective of this study was to identify the pauses that occur during ALS situations in high-fidelity simulation scenarios and the frequency and duration of these pauses.

METHODS

One hundred forty-two nursing students participated in this cross-sectional study, involving high-fidelity simulation scenario of cardiorespiratory arrest in a simulated hospital room. Pauses were assessed using an observation checklist.

RESULTS

Students performed the scenario in an average time of 8.32 (standard deviation = 1.13) minutes. Pauses between chest compressions were longer than recommended (mean = 0.36, standard deviation = 1.14). A strong positive correlation was found between the identification of the arrhythmia and the initiation of countershock (rs = 0.613, p < 0.001).

CONCLUSIONS

Nursing students generally performed ALS within the time limits recommended by resuscitation guidelines. Early identification of shockable rhythms may lead to early nurse-initiated defibrillation. Strategies to speed up the identification of arrhythmias should be put in place to minimise preshock pauses and improve ALS outcomes.

Precision Cardiac Arrest Resuscitation Based on Etiology

Cardiac arrest results from a broad range of etiologies that can be broadly grouped as sudden and asphyxial. Animal studies point to differences in injury pathways invoked in the heart and brain that drive injury and outcome after these different forms of cardiac arrest. Present guidelines largely ignore etiology in their management recommendations. Existing clinical data reveal significant heterogeneity in the utility of presently employed resuscitation and postresuscitation strategies based on etiology. The development of future neuroprotective and cardioprotective therapies should also take etiology into consideration to optimize the chances for successful translation.

Modeling severe functional impairment or death following ECPR in pediatric cardiac patients: Planning for an interventional trial

AIM

We aimed to characterize extracorporeal CPR (ECPR) outcomes in our center and to model prediction of severe functional impairment or death at discharge.

METHODS

All ECPR events between 2011 and 2019 were reviewed. The primary outcome measure was severe functional impairment or death at discharge (Functional Status Score [FSS] ≥ 16). Organ dysfunction was graded using the Pediatric Logistic Organ Dysfunction Score-2, neuroimaging using the modified Alberta Stroke Program Early Computed Tomography Score. Multivariable logistic regression was used to model FSS ≥ 16 at discharge.

RESULTS

Of the 214 patients who underwent ECPR, 182 (median age 148 days, IQR 14-827) had an in-hospital cardiac arrest and congenital heart disease and were included in the analysis. Of the 110 patients who underwent neuroimaging, 52 (47%) had hypoxic-ischemic injury and 45 (41%) had hemorrhage. In-hospital mortality was 52% at discharge. Of these, 87% died from the withdrawal of life-sustaining therapies; severe neurologic injury was a contributing factor in the decision to withdraw life-sustaining therapies in 50%. The median FSS among survivors was 8 (IQR 6-8), and only one survivor had severe functional impairment. At 6 months, mortality was 57%, and the median FSS among survivors was 6 (IQR 6-8, n = 79). Predictive models identified FSS at admission, single ventricle physiology, extracorporeal membrane oxygenation (ECMO) duration, mean PELOD-2, and worst mASPECTS (or DWI-ASPECTS) as independent predictors of FSS ≥ 16 (AUC = 0.931) and at 6 months (AUC = 0.924).

CONCLUSION

Mortality and functional impairment following ECPR in children remain high. It is possible to model severe functional impairment or death at discharge with high accuracy using daily post-ECPR data up to 28 days. This represents a prognostically valuable tool and may identify endpoints for future interventional trials.

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest

INTRODUCTION

In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear.

METHODS

We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age.

RESULTS

There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86).

CONCLUSIONS

Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Rapid-cycle deliberate practice improves time to defibrillation and reduces workload: A randomized controlled trial of simulation-based education

BACKGROUND

The optimal structure of simulation to train teams to perform pediatric advanced life support (PALS) requires further research. Most simulation is structured with an uninterrupted scenario with postsimulation debriefing (PSD). Rapid-cycle deliberate practice (RCDP) is structured with a series of simulations with microdebriefing quickly switching within action targeting specific performance goals.

OBJECTIVE

The objective was to compare team performance immediately after training, as well as learner workload, for teams trained using either PSD or RCDP.

METHODS

In 2018-2019, a total of 41 interprofessional teams of 210 residents and nurses were recruited from 250 eligible participants (84%) and randomized into either arm (RCDP or PSD) teaching the same objectives of resuscitation of a patient in PEA arrest, in the same time frame. The structure of the simulation varied. Demographic surveys were collected before training, the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) was administered immediately after training to assess workload during training and performance was assessed immediately after training using a pulseless ventricular tachycardia arrest with the primary outcome being time to defibrillation.

RESULTS

Thirty-nine teams participated over a 16-month time span. Performance of teams randomized to RCDP showed significantly better time to defibrillation, 100 s (95% confidence interval [CI] = 90-111), compared to PSD groups, 163 s (95% CI = 120-201). The workload of the groups also showed a lower total NASA-TLX score for the RCDP groups.

CONCLUSIONS

For team-based time-sensitive training of PALS, RCDP outperformed PSD. This may be due to a reduction in the workload faced by teams during training.

Variability in the Hemodynamic Response to Fluid Bolus in Pediatric Septic Shock

OBJECTIVES

Fluid boluses are commonly administered to improve the cardiac output and tissue oxygen delivery in pediatric septic shock. The objective of this study is to evaluate the effect of an early fluid bolus administered to children with septic shock on the cardiac index and mean arterial pressure, as well as on the hemodynamic response and its relationship with outcome.

DESIGN, SETTING, PATIENTS, AND INTERVENTIONS

We prospectively collected hemodynamic data from children with septic shock presenting to the emergency department or the PICU who received a fluid bolus (10 mL/kg of Ringers Lactate over 30 min). A clinically significant response in cardiac index-responder and mean arterial pressure-responder was both defined as an increase of greater than or equal to 10% 10 minutes after fluid bolus.

MEASUREMENTS AND MAIN RESULTS

Forty-two children with septic shock, 1 month to 16 years old, median Pediatric Risk of Mortality-III of 13 (interquartile range, 9-19), of whom 66% were hypotensive and received fluid bolus within the first hour of shock recognition. Cardiac index- and mean arterial pressure-responsiveness rates were 31% and 38%, respectively. We failed to identify any association between cardiac index and mean arterial pressure changes (r = 0.203; p = 0.196). Cardiac function was similar in mean arterial pressure- and cardiac index-responders and nonresponders. Mean arterial pressure-responders increased systolic, diastolic, and perfusion pressures (mean arterial pressure - central venous pressure) after fluid bolus due to higher indexed systemic vascular resistance and arterial elastance index. Mean arterial pressure-nonresponders required greater vasoactive-inotrope support and had higher mortality.

CONCLUSIONS

The hemodynamic response to fluid bolus in pediatric septic shock was variable and unpredictable. We failed to find a relationship between mean arterial pressure and cardiac index changes. The adverse effects of fluid bolus extended beyond fluid overload and, in some cases, was associated with reduced mean arterial pressure, perfusion pressures and higher vasoactive support. Mean arterial pressure-nonresponders had increased mortality. The response to the initial fluid bolus may be helpful to understand each patient's individualized physiologic response and guide continued hemodynamic management.

Echis coloratus envenomation in children: a retrospective case series

BACKGROUND

Antivenom has been used successfully to treat systemic and progressive, local manifestations of envenomations inflicted by Echis coloratus, the second most common cause of snake envenomation in Israel. There is a paucity of published data regarding the use of monovalent (equine) immunoglobulin G antivenom in children. This study describes outcomes from the regimen used in two large, tertiary care pediatric centers.

METHODS

A retrospective chart review of children admitted with definite or probable signs of Echis coloratus envenomation to Sourasky (Tel Aviv) and Soroka (Be'er Sheva) Medical Centers from January 1st 2008-to June 1st 2019. Extracted data included age, location of bite, time to hospital arrival, laboratory test results, complications, time to antivenom administration if indicated, adverse effects of the antivenom, and outcomes. Indications for antivenom were: diagnosis of Echis coloratus as the etiology of envenomation, local and systemic signs e.g. skin puncture wounds, swelling of the involved limb, local hematoma, and abnormal coagulation blood test results.

RESULTS

During the study period, 11 children were treated with intravenous Echis coloratus antivenom. Median age was 9 years and 10 of 11 patients were male. Two patients underwent fasciotomy; in one, compartment syndrome was diagnosed by pressure measurement, and in the second, clinically. One patient developed mild urticaria 30 min after initiation of the antivenom; the treatment was stopped and then restarted at a slower rate after he was treated with hydrocortisone and diphenhydramine. No further adverse reactions were observed.

CONCLUSIONS

In children, Echis coloratus antivenom appeared to be effective and safe for the treatment of systemic and progressive local manifestations of envenomation by Echis coloratus.

PediAppRREST: effectiveness of an interactive cognitive support tablet app in reducing deviations from guidelines in the management of paediatric cardiac arrest: protocol for a simulation-based randomised controlled trial

INTRODUCTION

Paediatric cardiac arrest (PCA), despite its low incidence, has a high mortality. Its management is complex and deviations from guideline recommendations occur frequently. We developed a new interactive tablet app, named PediAppRREST, to support the management of PCA. The app received a good usability evaluation in a previous pilot trial. The aim of the study is to evaluate the effectiveness of the PediAppRREST app in reducing deviations from guideline recommendations in PCA management.

METHODS AND ANALYSIS

This is a multicentre, simulation-based, randomised controlled, three-parallel-arm study. Participants are residents in Paediatric, Emergency Medicine, and Anaesthesiology programmes in Italy. All 105 teams (315 participants) manage the same scenario of in-hospital PCA. Teams are randomised by the study statistician into one of three study arms for the management of the PCA scenario: (1) an intervention group using the PediAppRREST app or (2) a control group Paediatric Advanced Life Support (CtrlPALS+) using the PALS pocket reference card; or (3) a control group (CtrlPALS-) not allowed to use any PALS-related cognitive aid. The primary outcome of the study is the number of deviations (delays and errors) in PCA management from PALS guideline recommendations, according to a novel checklist, named c-DEV15plus. The c-DEV15plus scores will be compared between groups with a one-way analysis of variance model, followed by the Tukey-Kramer multiple comparisons adjustment procedure in case of statistical significance.

ETHICS AND DISSEMINATION

The Ethics Committee of the University Hospital of Padova, coordinating centre of the trial, deemed the project to be a negligible risk study and approved it through an expedited review process. The results of the study will be disseminated in peer-reviewed journals, and at national and international scientific conferences. Based on the study results, the PediAppRREST app will be further refined and will be available for download by institutions/healthcare professionals.

TRIAL REGISTRATION NUMBER

NCT04619498; Pre-results.

Sustained Inflation During Chest Compression: A New Technique of Pediatric Cardiopulmonary Resuscitation That Improves Recovery and Survival in a Pediatric Porcine Model

Background

Chest compression (CC) during sustained inflations (CC+SI) compared with CC with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation in asphyxiated pediatric piglets will reduce time to return of spontaneous circulation (ROSC).

Methods and Results

Piglets (20–23 days of age, weighing 6.2–10.2 kg) were anesthetized, intubated, instrumented, and exposed to asphyxia. Cardiac arrest was defined as mean arterial blood pressure <25 mm Hg with bradycardia. After cardiac arrest, piglets were randomized to CC+SI (n=12) or CCaV (n=12) or sham (n=8). Sham‐operated animals had no asphyxia. Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded. There were no differences in baseline parameters or the duration and degree of asphyxiation. Median (interquartile range) Time to ROSC was 248 (41–346) seconds compared with 720 (167–720) seconds in the CC+SI group and CCaV group, respectively (P=0.0292). There was a 100% higher rate of ROSC in the CC+SI group versus CCaV group, with 10 (83%) versus 5 (42%) achieving ROSC (P=0.089), respectively. Piglets in the CC+SI and CCaV groups received intravenous epinephrine boluses to achieve ROSC (8/12 versus 10/12 P=0.639). There was a significantly higher minute ventilation in the CC+SI group, which was secondary to a 5‐fold increase in the number of inflations per minute and a 1.5‐fold increase in tidal volume.

Conclusions

CC+SI reduced time to ROSC and improved survival compared with using CCaV. CC+SI allowed passive ventilation of the lung while providing chest compressions. This technique warrants further studies to examine the potential to improve outcomes in pediatric patients with cardiac arrest.

Registration

URL: https://www.preclinicaltrials.eu; Unique identifier: PCTE0000152.