450 SECTION IV Pediatric Critical Care Cardiovascular Therefore, most experts agree that close monitoring and treatment of status epilepticus in the postarrest phase is important, although there is a[.]
450 S E C T I O N I V Pediatric Critical Care: Cardiovascular Therefore, most experts agree that close monitoring and treatment of status epilepticus in the postarrest phase is important, although there is a paucity of data showing that treatment of seizures improves outcomes In deciding on how to treat seizures in the postarrest period, providers must be aware of potential side effects of antiepileptic drugs and be prepared to treat them For example, causing severe hypotension with benzodiazepines and/or other antiepileptic drugs may provide more harm than benefit Other Considerations Contemporary Methods to Improve Cardiopulmonary Resuscitation Quality Intra-arrest Cardiopulmonary Resuscitation Quality Monitoring Technology Innovative technology, primarily using force transducers and accelerometers, has allowed resuscitation scientists and clinicians to measure CPR mechanics quantitatively during actual resuscitation attempts Research involving this technology has established the following as it pertains to pediatric cardiac arrest: (1) providing high-quality CPR is difficult even for professional rescuers,69,125–127 (2) outcomes from pediatric cardiac arrest are directly associated with the quality of CPR provided,17 and (3) incorporation of CPR quality data into education and patient care is a vital component of any comprehensive resuscitation quality improvement program.128 In a single-center study, the combination of focused bedside training with audiovisual feedback before the resuscitation, automated defibrillator CPR feedback during the resuscitation, and post–cardiac arrest debriefing after the resuscitation improved guideline compliance and survival outcomes In this study, favorable neurologic survival after pediatric ICU arrest improved from 29% to 50% with this approach.128 Currently, a clinical trial in the CPCCRN network funded by the National Heart, Lung, and Blood Institute is evaluating this resuscitation bundle of care to improve outcomes across 18 ICUs in the United States (ICU-RESUS: R01HL131544; trial completion anticipated March 2021) Recent work has also demonstrated that the use of a CPR coach, an individual solely focused on ensuring that CPR quality metrics are maintained during resuscitation, can improve CPR quality.129 Point-of-Care Bedside Training There is a substantial body of evidence showing a decline in CPR skills as early as months after conventional training In response, resuscitation scientists have evaluated an alternative CPR training approached termed Rolling Refreshers This is a point-of-care educational program that functions under a low-intensity, but highfrequency, paradigm—that is, trainees practice their CPR “on the job” with brief (,2 minutes) instruction/practice sessions Several studies have established that this approach improves initial skill acquisition and retention in ICU and non-ICU providers alike during simulated resuscitation.130–132 The AHA now offers Basic Life Support (BLS) recertification through this transformational approach: http://cpr.heart.org/AHAECC/CPRAndECC/Training/ RQI/UCM_476470_RQI.jsp Extracorporeal Cardiopulmonary Resuscitation Extracorporeal membrane oxygenation (ECMO) has been increasingly used during resuscitation when standard CPR alone does not result in ROSC In a large CPCCRN study of ICU CPR, more than 15% of the 77% of patients who achieved return of circulation did so through use of ECMO instituted during CPR.3 In children with medical or surgical cardiac diseases, Extracorporeal CPR (E-CPR) has been shown to improve survival to hospital discharge and can be effective even after prolonged CPR (.50 minutes).133 In a recent GWTG-R study that included patients from all illness categories who received at least 10 minutes of CPR, E-CPR was associated with improved rates of survival and favorable neurologic outcome at discharge compared with conventional CPR, even after propensity matching.134 The most recent PALS Guidelines states that E-CPR may be considered for pediatric patients with cardiac diagnoses but highlighted that existing ECMO protocols, expertise, and equipment should be in place.60 Suitability for E-CPR rescue should be individualized at the patient level with consideration of the reversibility of the underlying process in the ultimate decision rather than focusing on a specific disease category, such as cardiac versus noncardiac Controversies in Pediatric Cardiac Arrest Management Airway Management As previously mentioned, most pediatric cardiac arrests are triggered by respiratory deterioration As such, airway and ventilation management remain basic tenets of pediatric resuscitation However, it must be noted that tracheal intubation of critically ill children is increasingly being recognized as high risk for precipitating cardiac arrest and that intubation during resuscitation can potentially detract from other therapies Supporting that contention, a large observational cohort study demonstrated that tracheal intubation during cardiac arrest compared with no intubation is associated with worse rates of survival.135 Another identified that when intubation was not achieved on the first attempt, outcomes were worse.136 Similarly, a recent Cardiac Arrest Registry to Enhance Survival (CARES) study of pediatric OHCA found higher survival rates among children receiving bag-mask ventilation (BMV) compared with those who were intubated.137 As such, the 2019 PALS update states that BMV is reasonable when compared with advanced airway interventions for pediatric OHCA but was unable to make a recommendation regarding BMV versus advanced airway management for pediatric IHCA Further study as to why tracheal intubation may be associated with worse outcomes (e.g., interruptions in CPR for the procedure, decreased venous return due to increased intrathoracic pressure, poor CPR quality as the team is distracted during tracheal intubation) are necessary Ventilation During Pediatric Cardiopulmonary Resuscitation Despite children having much higher ventilation rates at baseline138 and more pediatric cardiac arrests being associated with respiratory deterioration, CPR guidelines recommend a ventilation rate of 10 breaths/minute for both children and adults This recommendation was made partly to simplify training but also to avoid the risk of excessive ventilation worsening hemodynamics, as is evident in some animal models of adult cardiac arrest.77,78 In contrast to these animal studies, a recent multicenter CPCCRN study found that higher rates were associated with improved CHAPTER 39 Performance of Cardiopulmonary Resuscitation in Infants and Children outcomes.139 Similar pediatric models have also found that higher rates may be beneficial to children.140 Cumulatively, these studies may indicate that future PALS Guidelines should reevaluate existing CPR ventilation rate recommendations for children and that prospective studies on this topic are needed Ventricular Fibrillation and Pulseless Ventricular Tachycardia Pediatric VF/pVT has been an underappreciated problem Believing that these lethal rhythms are rare in children can lead to a uniformly fatal outcome Reports indicate that these shockable rhythms occur in 27% of pediatric IHCAs at some time during CPR.41 The treatment of choice for short-duration VF is prompt defibrillation Adult studies have established that the mortality rate increases by 7% to 10% per minute of delay to defibrillation.25 In 2018, the corresponding pediatric study investigating the association between time to defibrillation and survival was published.26 Unlike the adult study, there was no association between delayed defibrillation and outcomes These surprising findings were likely due to known differences between pediatric and adult IHCA As a specific example, more pediatric IHCAs occur in ICUs in highly monitored patients Presumably, these patients are more likely to receive immediate high-quality CPR, which may make time to defibrillation less important as highquality CPR preserves the metabolic milieu for successful defibrillation longer In short, more work is clearly needed regarding optimal defibrillation strategies in children Regardless, a high index of suspicion for shockable rhythms, both as the initial rhythm and as subsequent rhythms later during cardiac arrest, and timely defibrillation when indicated remain of paramount importance Pediatric Automated External Defibrillators Automated external defibrillators (AEDs) have improved adult survival from VF and are recommended for use in children years or older with cardiac arrest.141–143 The available data suggest that some AEDs can accurately diagnose VF in children of all ages and rarely inaccurately recommend defibrillation The energy doses delivered by AEDs are high, but they are below the range demonstrated to cause harm in laboratory animal studies of shock toxicity Adapters with smaller defibrillation pads that dampen the amount of energy delivered have been developed as attachments to adult AEDs, facilitating their use in children Given these advances, consensus guidelines recommend that AEDs be used in younger children, including infants, when manual defibrillators are not available.144 Importantly, recent data demonstrate relatively low rates of AED application to children with OHCA,145 suggesting that this as an area for additional education and training 451 Summary Outcomes from pediatric cardiac arrest and CPR have improved in recent decades Perhaps the evolving understanding of pathophysiologic events during and after pediatric cardiac arrest and the developing fields of pediatric critical care and pediatric emergency medicine have contributed to these improvements In addition, exciting breakthroughs in basic and applied science laboratories, such as physiologically directed CPR, are on the immediate horizon for further implementation By strategically focusing therapies to specific phases of cardiac arrest, there is great promise that critical care interventions will lead the way to more successful cardiopulmonary and cerebral resuscitation in children Key References Berg RA, Nadkarni VM, Clark AE, et al Incidence and outcomes of cardiopulmonary resuscitation in PICUs Crit Care Med 2016;44(4): 798-808 Berg RA, Sutton RM, Reeder RW, et al Association between diastolic blood pressure during pediatric in-hospital cardiopulmonary resuscitation and survival Circulation 2018;137(17):1784-1795 Girotra S, Spertus JA, Li Y, et al Survival trends in pediatric in-hospital cardiac arrests: an analysis from Get With the Guidelines–Resuscitation Circ Cardiovasc Qual Outcomes 2013;6(1):42-49 Lasa JJ, Rogers RS, Localio R, et al Extracorporeal cardiopulmonary resuscitation (E-CPR) during pediatric in-hospital cardiopulmonary arrest is associated with improved survival to discharge: a report from the American Heart Association’s Get With The Guidelines–Resuscitation (GWTG-R) Registry Circulation 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2014;190(11):1255-1262 Topjian AA, Telford R, Holubkov R, et al Association of early postresuscitation hypotension with survival to discharge after targeted temperature management for pediatric out-of-hospital cardiac arrest: secondary analysis of a randomized clinical trial JAMA Pediatr 2018;172(2):143-153 The full reference list for this chapter is available at ExpertConsult.com e1 References Slonim AD, Patel KM, Ruttimann UE, Pollack MM Cardiopulmonary resuscitation in pediatric intensive care units Crit Care Med 1997;25(12):1951-1955 Atkins DL, Everson-Stewart S, Sears GK, et al Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest Circulation 2009;119(11):1484-1491 Berg RA, Nadkarni VM, Clark AE, et al Incidence and Outcomes of Cardiopulmonary Resuscitation in PICUs Crit Care Med 2016;44(4):798-808 Holmberg MJ, Ross CE, Fitzmaurice GM, et al Annual incidence of adult and pediatric in-hospital cardiac 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