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Geanacopoulos AT, Zielonka B, Fox MT, Kerr S, Chambers KD, Przybylski R, Burns MM. Pediatric antiarrhythmics and toxicity: A clinical review. J Am Coll Emerg Physicians Open 2024; 5:e13090. [PMID: 38371660 PMCID: PMC10869663 DOI: 10.1002/emp2.13090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 02/20/2024] Open
Abstract
Antiarrhythmic medications are fundamental in the acute and chronic management of pediatric arrhythmias. Particularly in the pediatric patient population, associated antiarrhythmic toxicities represent important potential adverse effects. Emergency medicine clinicians must be skilled in the detection, workup, and management of antiarrhythmic toxicity. This is a clinical review of the indications, pharmacology, adverse effects, and toxicologic treatment of antiarrhythmics commonly used in the pediatric patient population.
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Affiliation(s)
- Alexandra T. Geanacopoulos
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Benjamin Zielonka
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
- Department of CardiologyBoston Children's HospitalBostonMassachusettsUSA
| | - Miriam T. Fox
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Sarah Kerr
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | | | - Robert Przybylski
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
- Department of CardiologyBoston Children's HospitalBostonMassachusettsUSA
| | - Michele M. Burns
- Division of Emergency MedicineBoston Children's HospitalBostonMassachusettsUSA
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
- Harvard Medical Toxicology ProgramBoston Children's HospitalBostonMassachusettsUSA
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Yuerek M, Kozyak BW, Shankar VR. Advances in Extracorporeal Support Technologies in Critically Ill Children. Indian J Pediatr 2023; 90:501-509. [PMID: 36988821 PMCID: PMC10049895 DOI: 10.1007/s12098-023-04545-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/28/2023] [Indexed: 03/30/2023]
Abstract
The field of pediatric heart failure is evolving, and the patient population is growing as survival after complex congenital heart surgeries is improving. Mechanical circulatory support and extracorporeal respiratory support in critically ill children has progressed to a mainstay rescue modality in pediatric intensive care medicine. The need for mechanical circulatory support is growing, since the number of organ donors does not meet the necessity. This article aims to review the current state of available mechanical circulatory and respiratory support systems in acute care pediatrics, with an emphasis on the literature discussing the challenges associated with these complex support modalities.
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Affiliation(s)
- Mahsun Yuerek
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA.
| | - Benjamin W Kozyak
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Venkat R Shankar
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
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Martin-Gill C, Brown KM, Cash RE, Haupt RM, Potts BT, Richards CT, Patterson PD. 2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care. PREHOSP EMERG CARE 2023; 27:131-143. [PMID: 36369826 DOI: 10.1080/10903127.2022.2143603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel. OBJECTIVES We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel. METHODS We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing. CONCLUSIONS This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.
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Affiliation(s)
- Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathleen M Brown
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel M Haupt
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Benjamin T Potts
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Holgersen MG, Jensen TW, Breindahl N, Kjerulff JLB, Breindahl SH, Blomberg SNF, Wolthers SA, Andersen LB, Torp-Pedersen C, Mikkelsen S, Lippert F, Christensen HC. Pediatric out-of-hospital cardiac arrest in Denmark. Scand J Trauma Resusc Emerg Med 2022; 30:58. [DOI: 10.1186/s13049-022-01045-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022] Open
Abstract
Abstract
Background
Pediatric out-of-hospital cardiac arrest (POHCA) has received limited attention. All causes of POHCA and outcomes were examined during a 4-year period in a Danish nationwide register and prehospital medical records. The aim was to describe the incidence, reversible causes, and survival rates for POHCA in Denmark.
Methods
This is a registry-based follow-up cohort study. All POHCA for a 4-year period (2016–2019) in Denmark were included. All prehospital medical records for the included subjects were reviewed manually by five independent raters establishing whether a presumed reversible cause could be assigned.
Results
We identified 173 cases within the study period. The median incidence of POHCA in the population below 17 years of age was 4.2 per 100,000 persons at risk. We found a presumed reversible cause in 48.6% of cases, with hypoxia being the predominant cause of POHCA (42.2%). The thirty-day survival was 40%. Variations were seen across age groups, with the lowest survival rate in cases below 1 year of age. Defibrillators were used more frequently among survivors, with 16% of survivors defibrillated bystanders as opposed to 1.9% in non-survivors and 24% by EMS personnel as opposed to 7.8% in non-survivors. The differences in initial rhythm being shockable was 34% for survivors and 16% for non-survivors.
Conclusion
We found pediatric out-of-hospital cardiac arrests was a rare event, with higher incidence and mortality in infants compared to other age groups of children. Use of defibrillators was disproportionally higher among survivors. Hypoxia was the most common presumed cause among all age groups.
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Vitale L, Rodriguez B, Baetzel A, Christensen R, Haydar B. Complications associated with removal of airway devices under deep anesthesia in children: an analysis of the Wake Up Safe database. BMC Anesthesiol 2022; 22:223. [PMID: 35840903 PMCID: PMC9284878 DOI: 10.1186/s12871-022-01767-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background Previous studies examining removal of endotracheal tubes and supraglottic devices under deep anesthesia were underpowered to identify rare complications. This study sought to report all adverse events associated with this practice found in a large national database of pediatric anesthesia adverse events. Methods An extract of an adverse events database created by the Wake Up Safe database, a multi-institutional pediatric anesthesia quality improvement initiative, was performed for this study. It was screened to identify anesthetics with variables indicating removal of airway devices under deep anesthesia. Three anesthesiologists screened the data to identify events where this practice possibly contributed to the event. Event data was extracted and collated. Results One hundred two events met screening criteria and 66 met inclusion criteria. Two cardiac etiology events were identified, one of which resulted in the patient’s demise. The remaining 97% of events were respiratory in nature (64 events), including airway obstruction, laryngospasm, bronchospasm and aspiration. Some respiratory events consisted of multiple distinct events in series. Nineteen respiratory events resulted in cardiac arrest (29.7%) of which 15 (78.9%) were deemed preventable by local anesthesiologists performing independent review. Respiratory events resulted in intensive care unit admission (37.5%), prolonged intubation and temporary neurologic injury but no permanent harm. Provider and patient factors were root causes in most events. Upon investigation, areas for improvement identified included improving patient selection, ensuring monitoring, availability of intravenous access, and access to emergency drugs and equipment until emergence. Conclusions Serious adverse events have been associated with this practice, but no respiratory events were associated with long-term harm.
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Affiliation(s)
- Lisa Vitale
- Department of Pediatric Anesthesia, University of Michigan, Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA. .,4-917 Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA.
| | - Briana Rodriguez
- Department of Pediatric Anesthesia, University of Michigan, Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA.,US Anesthesia Partners Texas - South, P.O. Box 701090, San Antonio, TX, 78270, USA
| | - Anne Baetzel
- Department of Pediatric Anesthesia, University of Michigan, Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA.,4-951 Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA
| | - Robert Christensen
- Department of Pediatric Anesthesia, University of Michigan, Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA.,4-914 Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA
| | - Bishr Haydar
- Department of Pediatric Anesthesia, University of Michigan, Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA.,4-911 Mott Hospital, 1540 E Hospital Dr SPC 4245, Ann Arbor, MI, 48109-4245, USA
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Derinoz-Guleryuz O, Uysal-Yazici M, Udurgucu M, Karacan C, Akça H, Ongun EA, Ekinci F, Duman M, Akça-Çaglar A, Vatansever G, Bilen S, Uysalol M, Akcan-Yıldız L, Saz EU, Bal A, Piskin E, Sahin S, Kurt F, Anil M, Besli E, Alakaya M, Gültekingil A, Yılmaz R, Temel-Koksoy O, Kesici S, Akcay N, Cebisli E, Emeksiz S, Kılınc MA, Köker A, Çoban Y, Erkek N, Gurlu R, Eksi-Alp E, Apa H. The skills of defibrillation practice and certified life-support training in the healthcare providers in Turkey. Int J Clin Pract 2021; 75:e14978. [PMID: 34669998 DOI: 10.1111/ijcp.14978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
| | - Mutlu Uysal-Yazici
- Department of Pediatric Intensive Care, Ankara Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Muhammed Udurgucu
- Department of Pediatric Intensive Care, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Candemir Karacan
- Department of Pediatric Emergency, Dr. Sami Ulus Maternity and Children Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Halise Akça
- Department of Pediatric Emergency, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Ebru Atike Ongun
- Department of Pediatric Intensive Care, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Faruk Ekinci
- Department of Pediatric Intensive Care, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Murat Duman
- Department of Pediatric Emergency, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Ayla Akça-Çaglar
- Department of Pediatric Emergency, Dr. Sami Ulus Maternity and Children Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Goksel Vatansever
- Department of Pediatric Emergency, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Sevcan Bilen
- Department of Pediatric Emergency, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Metin Uysalol
- Department of Pediatric Emergency, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Leman Akcan-Yıldız
- Department of Pediatric Emergency, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Eylem Ulas Saz
- Department of Pediatric Emergency, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Alkan Bal
- Department of Pediatric Emergency, Faculty of Medicine, Manisa Celal Bayar University, Manisa, Turkey
| | - Etem Piskin
- Department of Pediatric Intensive Care, Faculty of Medicine, Bülent Ecevit University, Zonguldak, Turkey
| | - Sabiha Sahin
- Department of Pediatric Emergency, Faculty of Medicine, Eskişehir Osmangazi University, Eskisehir, Turkey
| | - Funda Kurt
- Department of Pediatric Emergency, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Murat Anil
- Department of Pediatric Emergency, Faculty of Medicine, İzmir Demokrasi University, Izmir, Turkey
| | - Esen Besli
- Department of Pediatric Emergency, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Mehmet Alakaya
- Department of Pediatric Intensive Care, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Ayse Gültekingil
- Department of Pediatric Emergency, Faculty of Medicine, Başkent University, Ankara, Turkey
| | - Resul Yılmaz
- Department of Pediatric Intensive Care, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Ozlem Temel-Koksoy
- Department of Pediatric Intensive Care, Konya Training and Research Hospital, Konya, Turkey
| | - Selman Kesici
- Department of Pediatric Intensive Care, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nihal Akcay
- Department of Pediatric Intensive Care, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Erdem Cebisli
- Department of Pediatric Intensive Care, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Serhat Emeksiz
- Department of Pediatric Intensive Care, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Mehmet Arda Kılınc
- Department of Pediatric Intensive Care, Diyarbakir Children Hospital, Diyarbakir, Turkey
| | - Alper Köker
- Department of Pediatric Intensive Care, Hatay State Hospital, Hatay, Turkey
| | - Yasemin Çoban
- Department of Pediatric Intensive Care, Hatay State Hospital, Hatay, Turkey
| | - Nilgün Erkek
- Department of Pediatric Emergency, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Ramazan Gurlu
- Department of Pediatric Emergency, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Emel Eksi-Alp
- Department of Pediatric Emergency, İstanbul University, Istanbul, Turkey
| | - Hursit Apa
- Department of Pediatric Emergency, Dr. Behçet Uz Children's Hospital, University of Health Sciences, Izmir, Turkey
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Akhlaghdoust M, Safari S, Davoodi P, Soleimani S, Khorasani M, Raoufizadeh F, Karimi H, Etesami E, Hamzehloei Z, Sadeghi SS, Heidaresfahani L, Ebadi Fard Azar T, Afshari Badrloo H. Awareness of Iranian Medical Sciences Students Towards Basic Life Support; a Cross-Sectional study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2021; 9:e40. [PMID: 34223185 PMCID: PMC8221544 DOI: 10.22037/aaem.v9i1.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction Augmentation of the number of trained basic life support (BLS) providers can remarkably reduce the number of cardiac arrest victims. The aim of this study was to evaluate the level of BLS awareness among students of medical sciences in Iran. Methods This multicenter cross-sectional study was performed on medical students at the 4 major medical schools in Tehran, the capital of Iran, between Jan 2018 and Feb 2019, using convenience sampling method. The level of medical sciences students' awareness of BLS was measured using an international questionnaire. Results Finally, 1210 students with the mean age of 21.2 ± 2.3 years completed the survey (79% female). 133 (10.9%) students had CPR experience and none had received any formal training. None of the responders could answer all questions correctly. The mean awareness score of participants was 11.93 ± 2.87 (range: 10.13 -17.25). The awareness score of participants was high in 49 (4.04 %) participants, moderate in 218 (18.01%), and low in 943 (77.93%) of studied cases. Conclusion Based on the findings of this study, more than 70% of the studied medical sciences students obtained a low score on BLS awareness.
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Affiliation(s)
- Meisam Akhlaghdoust
- Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,USERN Office, Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeid Safari
- Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,USERN Office, Functional Neurosurgery Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Poorya Davoodi
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Soleimani
- Islamic Azad University, TehranMedical Sciences Branch, Tehran, Iranslamic Azad University, TehranMedical Sciences Branch, Tehran, Iran
| | - Maryam Khorasani
- Islamic Azad University, TehranMedical Sciences Branch, Tehran, Iranslamic Azad University, TehranMedical Sciences Branch, Tehran, Iran
| | - Fatemeh Raoufizadeh
- Islamic Azad University, TehranMedical Sciences Branch, Tehran, Iranslamic Azad University, TehranMedical Sciences Branch, Tehran, Iran
| | - Hosna Karimi
- Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Elahe Etesami
- Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Zeynab Hamzehloei
- Islamic Azad University, TehranMedical Sciences Branch, Tehran, Iranslamic Azad University, TehranMedical Sciences Branch, Tehran, Iran
| | - Seyedeh Sara Sadeghi
- Islamic Azad University, TehranMedical Sciences Branch, Tehran, Iranslamic Azad University, TehranMedical Sciences Branch, Tehran, Iran
| | - Ladan Heidaresfahani
- Islamic Azad University, TehranMedical Sciences Branch, Tehran, Iranslamic Azad University, TehranMedical Sciences Branch, Tehran, Iran
| | - Tooba Ebadi Fard Azar
- Islamic Azad University, TehranMedical Sciences Branch, Tehran, Iranslamic Azad University, TehranMedical Sciences Branch, Tehran, Iran
| | - Haniyeh Afshari Badrloo
- Islamic Azad University, TehranMedical Sciences Branch, Tehran, Iranslamic Azad University, TehranMedical Sciences Branch, Tehran, Iran
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Salamah A, Mehrez M, Faheem A, El Amrousy D. Efficacy of Citicoline as a Neuroprotector in children with post cardiac arrest: a randomized controlled clinical trial. Eur J Pediatr 2021; 180:1249-1255. [PMID: 33169240 DOI: 10.1007/s00431-020-03871-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/30/2020] [Accepted: 11/04/2020] [Indexed: 02/08/2023]
Abstract
Brain hypoxia after cardiac arrest leads to damage of the neuronal cell membrane. Citicoline is necessary for the synthesis of cell membrane. We planned to assess the neuroprotective effect of citicoline in children after cardiac arrest. This randomized controlled trial was carried out at pediatric intensive care units (PICU) and surgical ICU at Tanta university hospital on 80 consecutive children surviving in-hospital cardiac arrest who were subdivided into two groups. Group I (citicoline group) included 40 children with post-cardiac arrest who received citicoline 10 mg /kg /12 h IV for 6 weeks plus other supportive measures and group II (control group) included 40 children with post-cardiac arrest who were managed with only supportive measures. All patients were evaluated for Glasgow coma score (GCS), modified Rankin scale (mRS) for children, seizures frequency, type and duration, and serum neuron-specific enolase (NSE) before and 3 months after the treatment. GCS and mRS significantly improved in citicholine group compared to the control group. Seizure frequency and duration, mortality, PICU and hospital stay significantly decreased in citicholine group compared to the control group. Serum NSE levels significantly decreased in citicholine group only. No side effects were recorded.Conclusion: Citicoline is a promising neuroprotective drug in children with post-cardiac arrest.Trial Registration: The study was registered at Pan African Clinical Trials Registry (PACTR) www.pactr.samrc.ac.za with trial number PACTR201907742119058. What is known? • Post-resuscitation brain injury is one of the major complications that can lead to death or disability. • CDP-choline has been studied for acute ischemic stroke in several adult studies because of its reparative effect. What is new? • Our study was the first in pediatrics that assessed the neuroprotective effect of CDP-choline on the brain in children after cardiac arrest. • We found that Citicoline is a promising neuroprotective drug in children with post-cardiac arrest.
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Affiliation(s)
- Abeer Salamah
- Pediatric Department, Kafr Elsheikh University, Kafr Elsheikh, Egypt
| | | | - Amany Faheem
- Anesthesiology and Surgical ICU Department, Tanta University, Tanta, Egypt
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Airway patency in children undergoing magnetic resonance imaging using neck collars: a single center, randomized, double-blind, prospective study. Braz J Anesthesiol 2021; 71:11-16. [PMID: 33712246 PMCID: PMC9373510 DOI: 10.1016/j.bjane.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 10/18/2020] [Indexed: 11/20/2022] Open
Abstract
Background and objectives Maneuvers precluding the downward shift of the mandibula and providing slight extension of the head have been shown to increase upper airway dimensions. This study aimed to investigate the role of Neck Collars (NC) in maintaining airway patency during Magnetic Resonance Imaging (MRI) examination in a pediatric population aged between 0 and 16 years. Methods One hundred twenty-five children were recruited in this prospective study. Subjects were randomly assigned to NC group (NC+) or standard imaging group (NC-). Measurements of anteroposterior and transverse dimensions and cross-sectional area were performed to determine the upper airway size at three distinct levels: soft palate, base of the tongue, and tip of the epiglottis. Results The anteroposterior diameter and cross-sectional area at the levels of base of the tongue and soft palate were significantly higher in NC+ patients compared to NC- patients. However, anteroposterior dimensions and cross-sectional areas at the epiglottis level were similar in the two groups. When patients were analyzed according to age groups of 0–2, 2–8, and 8–16 years, the anteroposterior diameter and cross-sectional area at the levels of base of the tongue and soft palate were significantly higher in NC+ patients compared to NC- patients in all age groups. Conclusions This study clearly demonstrates that the application of a NC may improve retropalatal end and retroglossal airway dimensions in a pediatric population undergoing MRI examination and receiving sedation in supine position.
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10
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Care Does Not Stop Following ROSC: A Quality Improvement Approach to Postcardiac Arrest Care. Pediatr Qual Saf 2021; 6:e392. [PMID: 33718747 PMCID: PMC7952102 DOI: 10.1097/pq9.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/04/2020] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Pediatric cardiac arrests carry significant morbidity and mortality. With increasing rates of return of spontaneous circulation, it is vital to optimize recovery conditions to decrease morbidity.
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Gok PG, Ozakin E, Acar N, Karakilic E, Kaya FB, Tekin N, Yazlamaz NO. Comparison of Endotracheal Intubation Skills With Video Laryngoscopy and Direct Laryngoscopy in Providing Airway Patency in a Moving Ambulance. J Emerg Med 2021; 60:752-759. [PMID: 33518375 DOI: 10.1016/j.jemermed.2020.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/24/2020] [Accepted: 12/06/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early and successful management of the airway in the prehospital and hospital settings is critical in life-threatening situations. OBJECTIVE We aimed to perform endotracheal intubation (ETI) by direct laryngoscopy (DL) and video laryngoscopy (VL) on airway manikins on a moving track and to compare the properties of intubation attempts. METHODS Overall, 79 participants with no previous VL experience were given 4 h of ETI training with DL and VL using a standard airway manikin. ETI skill was tested inside a moving ambulance. The number of attempts until successful ETI, ETI attempt times, time needed to see the vocal cords, and the degree of convenience of both ETI methods were recorded. RESULTS Overall, 22 of 79 individuals were men; mean age was 30.3 ± 4.5 years. No difference was found in the comparison of the two methods (p = 0.708). Time needed to see the vocal cords for those who were successful in their first attempt were between 1 and 8 s in both methods. In the VL method, time needed to see the vocal cords (p = 0.001) and the intubation time (p < 0.001) in the first attempt were shorter than in the DL method. The VL method was easier (p < 0.001). The success rate was 97.5% in DL and 93.7% in VL. CONCLUSIONS The VL method is rapid and easier to see the vocal cords and perform successful ETI. Therefore, it might be preferred in out-of-hospital ETI applications.
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Affiliation(s)
- Pakize Gozde Gok
- Department of Emergency Medicine, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Engin Ozakin
- Department of Emergency Medicine, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Nurdan Acar
- Department of Emergency Medicine, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Evvah Karakilic
- Department of Emergency Medicine, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Filiz B Kaya
- Department of Emergency Medicine, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Nurettin Tekin
- Ministry of Health, Provincial Ambulance Service, Eskisehir, Turkey
| | - Nazlı Ozcan Yazlamaz
- Department of Emergency Medicine, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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12
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Refaat M, Abohelwa MM, Ahmed M, Elgehiny A, Ibrahim M, Zakka P, El Rassi I, Bulbul Z, Bitar F, Arabi M. Arrhythmias in Neonates and Infants at a Tertiary Care Center. Cureus 2021; 13:e12861. [PMID: 33633891 PMCID: PMC7899244 DOI: 10.7759/cureus.12861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 11/05/2022] Open
Abstract
Background Limited data about arrhythmias in neonates and infants are coming out from the Middle East. Objectives To evaluate different types of arrhythmias in neonates and infants at the American University of Beirut Medical Center (AUBMC), a tertiary care center in Lebanon, with the focus on the nature of arrhythmia, treatment modalities and relation to surgery. Methods Data were collected retrospectively from the hospital records. We included all neonates and infants presenting to AUBMC between 2013 and 2017. Collected data included: the type of arrhythmia, the treatment modality used and its success, the need for additional modes of treatment, the relationship to congenital heart diseases, and the cardiac surgeries performed. Results Of 16,346 subjects admitted to AUBMC between 2013 and 2017, 90 subjects developed arrhythmias that required medical intervention. The most frequent types of arrhythmias were supraventricular tachycardia (62.22%), junctional ectopic tachycardia (13.33%), complete heart block (7.78%), atrial flutter (5.56%), multifocal atrial tachycardia (3.33%), Wolf Parkinson White Syndrome (3.33%), non-sustained ventricular tachycardia (2.22%), sinus pause (1.11%), and premature ventricular contractions (1.11%). Bivariate analysis showed a significant difference between arrhythmias not related to cardiac surgery and arrhythmias related to cardiac surgery in terms of the type of arrhythmia developed, the presence of congenital heart defect, prematurity, and electrolyte disturbances (P-value <0.005). However, multivariate logistic regression showed no significant difference between the two groups after adjustment for the significant variables (P-value > 0.05). Conclusion There is a significant difference between arrhythmias not related to cardiac surgery and arrhythmias related to cardiac surgery in neonates and infants at AUBMC. However, the difference disappears after adjusting for different variables.
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Affiliation(s)
- Marwan Refaat
- Cardiovascular Disease, American University of Beirut, Beirut, LBN
| | - Mostafa M Abohelwa
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Mohamed Ahmed
- Family Medicine, American University of Beirut, Beirut, LBN
| | - Amr Elgehiny
- Pediatrics, University of Texas Health Science Center at Houston, Houston, USA
| | - Maryam Ibrahim
- Internal Medicine, American University of Beirut Medical Center, Beirut, LBN
| | - Patrick Zakka
- Internal Medicine, Emory University School of Medicine, Atlanta, USA
| | - Isam El Rassi
- Cardiac Surgery, American University of Beirut, Beirut, LBN
| | - Ziad Bulbul
- Pediatric Cardiology, American University of Beirut, Beirut, LBN
| | - Fadi Bitar
- Pediatric Cardiology, American University of Beirut, Beirut, LBN
| | - Mariam Arabi
- Cardiology, American University of Beirut, Beirut, LBN
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13
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Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S469-S523. [PMID: 33081526 DOI: 10.1161/cir.0000000000000901] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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14
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Cheng A, Magid DJ, Auerbach M, Bhanji F, Bigham BL, Blewer AL, Dainty KN, Diederich E, Lin Y, Leary M, Mahgoub M, Mancini ME, Navarro K, Donoghue A. Part 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S551-S579. [PMID: 33081527 DOI: 10.1161/cir.0000000000000903] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, Lavonas EJ, Magid DJ. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S337-S357. [DOI: 10.1161/cir.0000000000000918] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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16
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Magid DJ, Aziz K, Cheng A, Hazinski MF, Hoover AV, Mahgoub M, Panchal AR, Sasson C, Topjian AA, Rodriguez AJ, Donoghue A, Berg KM, Lee HC, Raymond TT, Lavonas EJ. Part 2: Evidence Evaluation and Guidelines Development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S358-S365. [DOI: 10.1161/cir.0000000000000898] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The
2020 American Heart Association
(AHA)
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
is based on the extensive evidence evaluation performed in conjunction with the International Liaison Committee on Resuscitation. The Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups drafted, reviewed, and approved recommendations, assigning to each recommendation a Class of Recommendation (ie, strength) and Level of Evidence (ie, quality). The 2020 Guidelines are organized in knowledge chunks that are grouped into discrete modules of information on specific topics or management issues. The 2020 Guidelines underwent blinded peer review by subject matter experts and were also reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The AHA has rigorous conflict-of-interest policies and procedures to minimize the risk of bias or improper influence during development of the guidelines. Anyone involved in any part of the guideline development process disclosed all commercial relationships and other potential conflicts of interest.
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17
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Capobianco S, Weiss M, Schraner T, Stimec J, Neuhaus K, Neuhaus D. Checking the basis of intraosseous access-Radiological study on tibial dimensions in the pediatric population. Paediatr Anaesth 2020; 30:1116-1123. [PMID: 32720412 DOI: 10.1111/pan.13979] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malposition of intraosseous needles in pediatric patients is frequently reported. Incorrect needle length and penetration depth related to the puncture site and level are possible causes. AIMS Aim of this study was to analyze anatomic dimensions of the proximal tibia in the pediatric population with respect to intraosseous needle placement and needle tip position. METHODS Plain lower leg radiographs of children aged from birth to 16 years of age were analyzed. Pretibial tissue layer, cortical bone thickness, and the diameter of the medullary cavity were measured at two different puncture levels. Data were analyzed as descriptive statistics and by polynomial regression plots and set in context to commonly used EZ-IO® needle lengths of 15 and 25 mm. RESULTS Radiographs from 190 patients (104 boys/86 girls) were included. When fully inserted to skin level, up to 10.5% of needles do not reach medullary cavity at one and 18.5% at two patient's fingerbreadths distal to tibial tuberosity. The opposite cortical wall is touched or penetrated in 16% and 25%, respectively. Up to 96% of too deep needle tip positions occur in children younger than 24 months, as do too superficial tip positions in 59%. CONCLUSIONS Puncture level and needle length have a great influence on potential needle tip positions. Infants and toddlers are at highest risk for malpositioning. Due to relevant growth-related differences in tibial anatomy, an age-related and well-reflected approach is crucial to successfully establish intraosseous access.
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Affiliation(s)
- Stéphanie Capobianco
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
| | - Thomas Schraner
- Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland.,Department of Diagnostic Imaging, University Children's Hospital, Zurich, Switzerland
| | - Jennifer Stimec
- Division of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kathrin Neuhaus
- Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland.,Division of Plastic and Reconstructive Surgery, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Diego Neuhaus
- Department of Anesthesia, University Children's Hospital, Zurich, Switzerland.,Children's Research Centre (CRC), University Children's Hospital Zurich, Zurich, Switzerland
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18
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Abstract
Pediatric cardiac arrest is a relatively rare but devastating presentation in infants and children. In contrast to adult patients, in whom a primary cardiac dysrhythmia is the most likely cause of cardiac arrest, pediatric patients experience cardiovascular collapse most frequently after an initial respiratory arrest. Aggressive treatment in the precardiac arrest state should be initiated to prevent deterioration and should focus on support of oxygenation, ventilation, and hemodynamics, regardless of the presumed cause. Unfortunately, outcomes for pediatric cardiac arrest, whether in hospital or out of hospital, continue to be poor.
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Affiliation(s)
- Nathan W Mick
- Department of Emergency Medicine, Pediatric Emergency Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA; Tufts University School of Medicine, Boston, MA, USA.
| | - Rachel J Williams
- Tufts University School of Medicine, Boston, MA, USA; Pediatric Emergency Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA
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19
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Scarpati G, Baldassarre D, Oliva F, Pascale G, Piazza O. Ionized or Total Magnesium levels, what should we measure in critical ill patients? Transl Med UniSa 2020; 23:68-76. [PMID: 34447718 PMCID: PMC8370522 DOI: 10.37825/2239-9747.1015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Monitoring and measuring magnesium (Mg) values are essential to prevent the development of numerous complications in perioperative medicine and critically ill patients. Although previous studies suggest that measuring free ionized magnesium (iMg) is more useful for estimating Mg status, clinicians currently rely on measurement of total serum magnesium to determine if supplemental magnesium is needed. In this review, we analyzed the recent literature to decide whether it is better to measure ionized serum Mg or total serum Mg when assessing magnesium status, whether iMg predicts clinical outcome, and what are the difficulties in measuring serum iMg levels in intensive care patients and perioperative medicine.
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20
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Siebert JN, Lacroix L, Cantais A, Manzano S, Ehrler F. The Impact of a Tablet App on Adherence to American Heart Association Guidelines During Simulated Pediatric Cardiopulmonary Resuscitation: Randomized Controlled Trial. J Med Internet Res 2020; 22:e17792. [PMID: 32292179 PMCID: PMC7287744 DOI: 10.2196/17792] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/22/2020] [Accepted: 03/23/2020] [Indexed: 12/13/2022] Open
Abstract
Background Evidence-based best practices are the cornerstone to guide optimal cardiopulmonary arrest resuscitation care. Adherence to the American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite advances in resuscitation science and survival improvement over the last decades, only approximately 38% of children survive to hospital discharge after in-hospital cardiac arrest and only 6%-20% after out-of-hospital cardiac arrest. Objective We investigated whether a mobile app developed as a guide to support and drive CPR providers in real time through interactive pediatric advanced life support (PALS) algorithms would increase adherence to AHA guidelines and reduce the time to initiation of critical life-saving maneuvers compared to the use of PALS pocket reference cards. Methods This study was a randomized controlled trial conducted during a simulation-based pediatric cardiac arrest scenario caused by pulseless ventricular tachycardia (pVT). A total of 26 pediatric residents were randomized into two groups. The primary outcome was the elapsed time in seconds in each allocation group from the onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, including the time intervals between defibrillation attempts and drug doses, shock doses, and the number of shocks. All outcomes were assessed for deviation from AHA guidelines. Results Mean time to the first defibrillation attempt (121.4 sec, 95% CI 105.3-137.5) was significantly reduced among residents using the app compared to those using PALS pocket cards (211.5 sec, 95% CI 162.5-260.6, P<.001). With the app, 11 out of 13 (85%) residents initiated chest compressions within 60 seconds from the onset of pVT and 12 out of 13 (92%) successfully defibrillated within 180 seconds. Time to all other defibrillation attempts was reduced with the app. Adherence to the 2018 AHA pVT algorithm improved by approximately 70% (P=.001) when using the app following all CPR sequences of action in a stepwise fashion until return of spontaneous circulation. The pVT rhythm was recognized correctly in 51 out of 52 (98%) opportunities among residents using the app compared to only 19 out of 52 (37%) among those using PALS cards (P<.001). Time to epinephrine injection was similar. Among a total of 78 opportunities, incorrect shock or drug doses occurred in 14% (11/78) of cases among those using the cards. These errors were reduced to 1% (1/78, P=.005) when using the app. Conclusions Use of the mobile app was associated with a shorter time to first and subsequent defibrillation attempts, fewer medication and defibrillation dose errors, and improved adherence to AHA recommendations compared with the use of PALS pocket cards.
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Affiliation(s)
- Johan N Siebert
- Department of Pediatric Emergency Medicine, Geneva Children's Hospital, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Laurence Lacroix
- Department of Pediatric Emergency Medicine, Geneva Children's Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Aymeric Cantais
- Pediatric Emergency Department, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Sergio Manzano
- Department of Pediatric Emergency Medicine, Geneva Children's Hospital, Geneva University Hospitals, Geneva, Switzerland
| | - Frederic Ehrler
- Diagnostic Department, Geneva University Hospitals, Geneva, Switzerland
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21
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Holmberg MJ, Ross CE, Atkins DL, Valdes SO, Donnino MW, Andersen LW. Lidocaine versus amiodarone for pediatric in-hospital cardiac arrest: An observational study. Resuscitation 2020; 149:191-201. [PMID: 31954741 PMCID: PMC10416093 DOI: 10.1016/j.resuscitation.2019.12.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/25/2019] [Accepted: 12/02/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lidocaine and amiodarone are both included in the pediatric cardiac arrest guidelines as treatments of shock-refractory ventricular fibrillation or pulseless ventricular tachycardia, although there is limited evidence to support this recommendation. METHODS In this cohort study from the Get With The Guidelines - Resuscitation registry, we included pediatric patients (≤18 years) with an in-hospital cardiac arrest between 2000 and 2018, who presented with an initial or subsequent shockable rhythm (ventricular fibrillation and pulseless ventricular tachycardia). Patients receiving amiodarone were matched to patients receiving lidocaine based on a propensity score, calculated from multiple patient, event, and hospital characteristics. RESULTS A total of 365 patients were available for the analysis, of which 180 (49%) patients were matched on the propensity score. The median age in the raw cohort was 6 (quartiles, 0.5-14) years, 164 (45%) patients were female, and 238 (65%) patients received an antiarrhythmic for an initial shockable rhythm. In the matched cohort, there were no statistically significant differences between patients receiving lidocaine compared to amiodarone in return of spontaneous circulation (RR, 0.99 [95%CI, 0.82-1.19]; p = 0.88), survival to 24 h (RR, 1.02 [95%CI, 0.76-1.38]; p = 0.88), survival to hospital discharge (RR, 1.01 [95%CI, 0.63-1.63]; p = 0.96), and favorable neurological outcome (RR, 0.65 [95%CI, 0.35-1.21]; p = 0.17). The results remained consistent in multiple sensitivity analyses. CONCLUSIONS In children with cardiac arrest receiving antiarrhythmics for a shockable rhythm, there was no significant difference in clinical outcomes between those receiving lidocaine compared to amiodarone.
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Affiliation(s)
- Mathias J Holmberg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.
| | - Catherine E Ross
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Dianne L Atkins
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Santiago O Valdes
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Michael W Donnino
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Lars W Andersen
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Intensive Care Medicine, Randers Regional Hospital, Randers, Denmark.
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22
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Gul SS, Cohen SA, Avery KL, Balakrishnan MP, Balu R, Chowdhury MAB, Crabb D, Huesgen KW, Hwang CW, Maciel CB, Murphy TW, Han F, Becker TK. Cardiac arrest: An interdisciplinary review of the literature from 2018. Resuscitation 2020; 148:66-82. [PMID: 31945428 DOI: 10.1016/j.resuscitation.2019.12.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/23/2019] [Accepted: 12/15/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest (CA). The goals of the review are to illustrate best practices and help reduce knowledge silos by disseminating clinically relevant advances in the field of CA across disciplines. METHODS An electronic search of PubMed using keywords related to CA was conducted. Title and abstracts retrieved by these searches were screened for relevancy, separated by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and importance. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors and reviewer scores were assessed using Wilcoxon signed-rank test. RESULTS A total of 9119 articles were identified on initial search; of these, 1214 were scored after screening for relevance and deduplication, and 80 underwent full critique. Prognostication & Outcomes category comprised 25% and Epidemiology & Public Health 17.5% of fully reviewed articles. There were no differences between editor and reviewer scoring. CONCLUSIONS The total number of articles demonstrates the need for an accessible source summarizing high-quality research findings to serve as a high-yield reference for clinicians and scientists seeking to absorb the ever-growing body of CA-related literature. This may promote further development of the unique and interdisciplinary field of CA medicine.
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Affiliation(s)
- Sarah S Gul
- Department of Surgery, Yale University, New Haven, CT, United States
| | - Scott A Cohen
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - K Leslie Avery
- Division of Pediatric Critical Care, Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | | | - Ramani Balu
- Division of Neurocritical Care, Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | | | - David Crabb
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Karl W Huesgen
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Charles W Hwang
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Carolina B Maciel
- Division of Neurocritical Care, Department of Neurology, University of Florida, Gainesville, FL, United States; Department of Neurology, Yale University, New Haven, CT, United States
| | - Travis W Murphy
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Francis Han
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States
| | - Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, FL, United States.
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23
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Favié LMA, Huitema ADR, van den Broek MPH, Rademaker CMA, de Haan TR, van Straaten HLM, Simons SHP, Rijken M, Nuytemans DHGM, Egberts TCG, Groenendaal F. Lidocaine as treatment for neonatal seizures: Evaluation of previously developed population pharmacokinetic models and dosing regimen. Br J Clin Pharmacol 2020; 86:75-84. [PMID: 31663153 PMCID: PMC6983510 DOI: 10.1111/bcp.14136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/08/2019] [Accepted: 09/10/2019] [Indexed: 01/28/2023] Open
Abstract
AIMS Lidocaine is used to treat neonatal seizures refractory to other anticonvulsants. It is effective, but also associated with cardiac toxicity. Previous studies have reported on the pharmacokinetics of lidocaine in preterm and term neonates and proposed a dosing regimen for effective and safe lidocaine use. The objective of this study was to evaluate the previously developed pharmacokinetic models and dosing regimen. As a secondary objective, lidocaine effectiveness and safety were assessed. METHODS Data from preterm neonates and (near-)term neonates with and without therapeutic hypothermia receiving lidocaine were included. Pharmacokinetic analyses were performed using non-linear mixed effects modelling. Simulations were performed to evaluate the proposed dosing regimen. Lidocaine was considered effective if no additional anticonvulsant was required and safe if no cardiac adverse events occurred. RESULTS Data were available for 159 neonates; 50 (31.4%) preterm and 109 term neonates, of whom 49 (30.8%) were treated with therapeutic hypothermia. Lidocaine clearance increased with postmenstrual age by 0.69%/day (95% confidence interval 0.54-0.84%). During therapeutic hypothermia (33.5°C), lidocaine clearance was reduced by 21.8% (7.26%/°C, 95% confidence interval 1.63-11.2%) compared to normothermia (36.5°C). Simulations demonstrated that the proposed dosing regimen leads to adequate average lidocaine plasma concentrations. Effectiveness and safety were assessed in 92 neonates. Overall effectiveness was 53.3% (49/92) and 56.5% (13/23) for neonates receiving the proposed dosing regimen. No cardiac toxicity was observed. CONCLUSION Lidocaine pharmacokinetics was adequately described across the entire neonatal age range. With the proposed dosing regimen, lidocaine can provide effective and safe treatment for neonatal seizures.
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Affiliation(s)
- Laurent M A Favié
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Carin M A Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Timo R de Haan
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Sinno H P Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique Rijken
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Debbie H G M Nuytemans
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL, Lasa JJ, Ley SJ, Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2020; 145:peds.2019-1361. [PMID: 31727859 DOI: 10.1542/peds.2019-1361] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.
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Duff JP, Topjian AA, Berg MD, Chan M, Haskell SE, Joyner BL, Lasa JJ, Ley SJ, Raymond TT, Sutton RM, Hazinski MF, Atkins DL. 2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2019; 140:e904-e914. [PMID: 31722551 DOI: 10.1161/cir.0000000000000731] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32°C to 34°C followed by 36°C to 37.5°C, or to use targeted temperature management of 36°C to 37.5°C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.
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Holmberg MJ, Wiberg S, Ross CE, Kleinman M, Hoeyer-Nielsen AK, Donnino MW, Andersen LW. Trends in Survival After Pediatric In-Hospital Cardiac Arrest in the United States. Circulation 2019; 140:1398-1408. [PMID: 31542952 DOI: 10.1161/circulationaha.119.041667] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac arrest in hospitalized children is associated with poor outcomes, but no contemporary study has reported whether the trends in survival have changed over time. In this study, we examined temporal trends in survival for pediatric patients with an in-hospital pulseless cardiac arrest and pediatric patients with a nonpulseless cardiopulmonary resuscitation event from 2000 to 2018. METHODS This was an observational study of hospitalized pediatric patients (≤18 years of age) who received cardiopulmonary resuscitation from January 2000 to December 2018 and were included in the Get With The Guidelines-Resuscitation registry, a United States-based in-hospital cardiac arrest registry. The primary outcome was survival to hospital discharge, and the secondary outcome was return of spontaneous circulation (binary outcomes). Generalized estimation equations were used to obtain unadjusted trends in outcomes over time. Separate analyses were performed for patients with a pulseless cardiac arrest and patients with a nonpulseless event (bradycardia with poor perfusion) requiring cardiopulmonary resuscitation. A subgroup analysis was conducted for shockable versus nonshockable initial rhythms in pulseless events. RESULTS A total of 7433 patients with a pulseless cardiac arrest and 5751 patients with a nonpulseless event were included for the analyses. For pulseless cardiac arrests, survival was 19% (95% CI, 11%-29%) in 2000 and 38% (95% CI, 34%-43%) in 2018, with an absolute change of 0.67% (95% CI, 0.40%-0.95%; P<0.001) per year, although the increase in survival appeared to stagnate following 2010. Return of spontaneous circulation also increased over time, with an absolute change of 0.83% (95% CI, 0.53%-1.14%; P<0.001) per year. We found no interaction between survival to hospital discharge and the initial rhythm. For nonpulseless events, survival was 57% (95% CI, 39%-75%) in 2000 and 66% (95% CI, 61%-72%) in 2018, with an absolute change of 0.80% (95% CI, 0.32%-1.27%; P=0.001) per year. CONCLUSIONS Survival has improved for pediatric events requiring cardiopulmonary resuscitation in the United States, with a 19% absolute increase in survival for in-hospital pulseless cardiac arrests and a 9% absolute increase in survival for nonpulseless events between 2000 and 2018. However, survival from pulseless cardiac arrests appeared to have reached a plateau following 2010.
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Affiliation(s)
- Mathias J Holmberg
- Department of Emergency Medicine, Horsens Regional Hospital, Horsens, Denmark (M.J.H.).,Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark (M.J.H., L.W.A.)
| | - Sebastian Wiberg
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Cardiology, Copenhagen University Hospital, Denmark (S.W.)
| | - Catherine E Ross
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Division of Medical Critical Care, Department of Pediatrics (C.E.R.), Boston Children's Hospital, Harvard Medical School, MA
| | - Monica Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine (M.K.), Boston Children's Hospital, Harvard Medical School, MA
| | - Anne Kirstine Hoeyer-Nielsen
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Clinical Research, Center for Prehospital and Emergency Research, Aalborg University, Denmark (A.K.H.-N.)
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine (M.W.D.), Beth Israel Deaconess Medical Center, Boston, MA
| | - Lars W Andersen
- Center for Resuscitation Science, Department of Emergency Medicine (M.J.H., S.W., C.E.R., A.K.H.-N., M.W.D., L.W.A.), Beth Israel Deaconess Medical Center, Boston, MA.,Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Denmark (M.J.H., L.W.A.)
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Lin YR, Li CJ, Huang CC, Lee TH, Chen TY, Yang MC, Chou CC, Chang CF, Huang HW, Hsu HY, Chen WL. Early Epinephrine Improves the Stabilization of Initial Post-resuscitation Hemodynamics in Children With Non-shockable Out-of-Hospital Cardiac Arrest. Front Pediatr 2019; 7:220. [PMID: 31245334 PMCID: PMC6563720 DOI: 10.3389/fped.2019.00220] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/15/2019] [Indexed: 11/22/2022] Open
Abstract
Background: In children with non-shockable out-of-hospital cardiac arrest, early epinephrine (EE) might help to establish the return of spontaneous circulation (ROSC) and be associated with survival. In the present study, we aimed to analyze the effects of EE on outcomes and post-resuscitation hemodynamics in children with non-shockable OHCA. Methods: This was a retrospective analysis of data from 216 children (<19 years) who had suffered non-traumatic and non-shockable OHCA and received epinephrine for resuscitation (Jan 1, 2006-Dec 31, 2014). Demographics, pre-/in-hospital information, and the time to the first dose of epinephrine were recorded. Early post-resuscitation hemodynamics (the first hour after sustained ROSC), survival and good neurological outcomes (Pediatric Cerebral Performance Category Scales 1 or 2) were analyzed by the time to epinephrine-classified as early (EE): <15 min, intermediate (IE): 15-30 min, or late (LE): >30 min. Results: Twenty-eight (13.0%) children survived to discharge, but only 17 (7.9%) had good neurological outcomes. In all, 41 (18.9%) children received EE; in comparison to IE and LE, this was significantly associated with tachycardia (73.9%) in the post-resuscitation period (p < 0.05). Tachycardia (OR: 7.41, 95% CI: 1.96-29.31) and hypertension (OR: 6.03, 95% CI: 1.85-13.77) were significantly associated with EE after adjusting for confounding factors. EE was also significantly associated with better overall outcomes than ME and LE (any ROSC, sustained ROSC, survival to the intensive care unit, admission, survival to discharge and good neurological outcomes, all p < 0.05). Conclusions: EE helped to establish ROSC but was also associated with more tachycardia and hypertension in the early post-resuscitation period. In children with non-traumatic and non-shockable OHCA, EE was associated with a higher survival rate and better neurological outcomes than were ME and LE.
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Affiliation(s)
- Yan-Ren Lin
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung City, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chao-Jui Li
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City, Taiwan.,Department of Leisure and Sports Management, Cheng Shiu University, Kaohsiung City, Taiwan
| | - Cheng-Chieh Huang
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Tsung-Han Lee
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
| | - Tren-Yi Chen
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Mei-Chueh Yang
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chu-Chung Chou
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung City, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chin-Fu Chang
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Hsi-Wen Huang
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Hsiu-Ying Hsu
- Department of Emergency Medicine, Changhua Christian Hospital, Changhua City, Taiwan.,Department of Nursing, Dayeh University, Changhua City, Taiwan.,Department of Nursing, Changhua Christian Hospital, Changhua City, Taiwan
| | - Wen-Liang Chen
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan
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