Pediatric Cardiac Arrest

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1 Committee on the Treatment of Cardiac Arrest: Current Status and Future Directions Pediatric Cardiac Arrest Vinay Nadkarni MD, MS Endowed Chair, Anesthesia and Critical Care Medicine Co-chair, International Liaison Committee on Resuscitation The Children s Hospital of Philadelphia The University of Pennsylvania Perelman School of Medicine

2 Vinay Nadkarni: Disclosures Employment: University of Pennsylvania Research Grants: National Institutes of Health (Cardiac Arrest, Cardiopulmonary bypass, Glucose Control, Airway Registry) Canadian Institute of Healthcare Research (CPR/EWS) R-Baby Foundation (Simulation) Nihon-Kohden (CO2 Monitoring) Laerdal Medical (CPR Learning Laboratory: completed) Zoll Corporation (CPR Learning Laboratory Network) Science Advisory Boards (Volunteer) International Liaison Committee on Resuscitation (ILCOR) AHA Get with the Guidelines-Resuscitation Society of Critical Care Medicine, Council Pediatric Acute Lung Injury and Sepsis Investigators (PALISI)

3 Adults: 10,000 Quality of lifeyears / day Children: 3500 Quality of lifeyears / day Adults: 1,000 / day Children: 50 / day

4 Population-based Incidence ROC Out-of-hospital Cardiac Arrest Age Incidence <1 yr 78/100, yrs 4/100, /100,000 Adults 95/100,000 Atkins, Circ 2009

5 Kids are not just little adults!

6 One Size may not fit all!. But, the principles of: -assessment -monitoring -feedback -quality are the same!!

7 Pediatric focus on the first breath of life...not on the last gasp of death

8 Approx 6 million babies

9 Pre-Arrest Post-Arrest stabilization Cardiac Arrest CPR No Flow Low Flow Low, Normal or High Flow PROTECTION PRESERVATION RESUSCITATION RESUSCITATION /REGENERATION Rapid Recognition Call Response Prompt CC Defibrillate if VF Push hard, Push Fast Minimize interruption Full recoil Assist ventilation? Vasopressors? Cooling? Targeted Temperature Management Blood pressure / Vasoactives Oxygen titration Seizures Ventilation (CO2) Sedation Fluid Early Mobilization/Rehabilitation Goal Directed Care

10 Gap between Training and Implementation CHALLENGES NOTED DURING SIMULATIONS % of Centers with problems Child Weight Estimates 34% IV/IO preparation IV Fluid Bolus Order Glucose bolus 69% 89% 97% Hunt E et al. Pediatrics 2006

11 Compliance with Guidelines Sutton Pediatrics 2009

12

13 Sudden Cardiac Death in Children and Young Adults Affects 3 to 4 young Americans / day Often genetic or anatomic heart problem, detectable by screening Only 1/3 of our 15 million high school students are trained in to respond with CPR and AEDs If bystander CPR could be increased from current 40% to near 100%, there is potential to save 72,000 lives/year and > 1 million Quality of Life years

14 Infants undergoing Targeted Temperature Management with a Cooling Blanket or Cooling Cap

15 Intraosseous Vascular Access

16 Time to Desaturation < 90% Normal Adult: Ill Adult: Normal 1 year old: Obese adult / Pregnant: Critically ill infant: 8 min 5 min 4 min 3 4 min < 1 min Benumof: Textbook of Anesthesia 1997

17 Challenges: Etiology based approach Airway Trauma Overdose Submersion Newly born Dysrhythmia Sudden VF Prolonged VF Acute Coronary Syndromes

18 QOL after Arrest and Resuscitation Neurodevelopmental Outcome Neurodevelopmental Outcome 1. Intelligence 2. Academic Achievement 3. Cognitive Functioning 4. Gross & Fine Motor Skills 5. Speech and Language Development Cardiac Arrest Death Survival Morbidity Associated with Arrest Traditional Resuscitation Outcome Measures Psychosocial Morbidity Characteristics of the Environment 1. Family Functioning 2. Caregiver Stress 3. Post-Traumatic Growth Characteristics of the Individual 1. Self-Perception 2. Behavior 3. Post-traumatic Stress 4. Trait Anxiety 5. Coping QOL Therapeutic Interventions Associated with Resuscitation Interventions to Reduce Morbidity

19 Overview about Pediatric Cardiac Arrest Out-of-hospital Pediatric Cardiopulmonary Arrest: Respiratory Etiology Poor Outcome (1 to 8%) Rare witnessed, monitored or shockable initial rhythms In-Hospital Pediatric Cardiopulmonary Arrest Combined Respiratory/Cardiac Etiology 70% survive event, 37% survive to Discharge (75% of these neurologically intact) Commonly witnessed, monitored and common shockable rhythms (10-25%)

20 Improved Survival and Quality of Life 1960 s to % Shock Leukemia HIV Congenital Heart Disease Cardiac Arrest 5%

21 In-hospital cardiac arrests CHOP children with pulseless Cardiac Arrest 2/18 (11%) survived to D/C 0/21 survived after >2 doses of epi Nichols D, Kettrick R, Swedlow D Ludwig S. Peds Emerg Care 1986

22 In-hospital cardiac arrests Children s National (CNMC) pulseless arrests 5/53 (9%) survived to D/C 0/31 survived after >2 doses of epi No survivors when CPR >10 min Zaritsky A, Nadkarni V, et al. AEM 1987

23 Survival outcomes after In-Hospital Pulseless Cardiac Arrest 60% 70% 31% 27% Nadkarni et al. JAMA 2006 Girotra et al. CIRC 2011

24 IHCA Survival Improving GWTG-R: 1,031 children Risk-adjusted Survival Rate Increased 14.3% in 2000 to 43.5% in 2009 Adj rate ratio/year 1.08; 95% CI [1.01,1.16] Girotra, Spertus, Li, Berg, Nadkarni, Chan Circ 2012

25 Is Rescue Breathing Necessary for Pediatric Bystander CPR?

26 Bystander CPR for Pediatric OHCA 30-day Good Neurologic Survival Non-cardiac Cause: 71% of 5178 OHCAs CC+RB CC only No CPR 45/624* 7.2% 6/380* 1.6% 53/ % * OR 5.5 (CI ) CC+RB vs CC Kitamura, Lancet 2010

27 Bystander CPR for Pediatric OHCA 30-day Good Neurologic Survival Cardiac Cause: 29% of 5178 OHCAs CC+RB CC only No CPR 28/282* 9.9% 14/158* 8.9% 14/ % * OR 2.2 (CI ) CC+RB & CC vs No CPR Kitamura, Lancet 2010

28 Goto Y et al: J Am Heart Assoc 2014

29 Goto Y et al: J Am Heart Assoc 2014

30 Figure 1. Crude Rates of 1-month Outcomes after Out-of- Hospital Cardiac Arrest in Japanese Children ( ) All, P < % By Y GOTO from Kanazawa University Hospital

31 Early Recognition and Response Rapid Response Teams (RRT) Medical Emergency Teams (MET)

32 Shift of IHCA from Ward to PICU GWTG-R CPCCRN Study Berg, Sutton, Meert, Berger, Wessel, Nadkarni, CPCCRN. CCM 2013

33 Brain: Goal Directed therapy Temperature management Cerebral perfusion BP Management Oxygen Titration Control of seizures Glucose control

34 Questions about hypothermia 1. Who should be cooled? 2. When to cool? Arrest ROSC 3. How to cool? temperature time 4. How deep to cool? Slide modified from T. van den Hoek, MD, U Chicago 5. How long to keep cool? 6. How to rewarm?

35 Therapeutic Hypothermia After Pediatric Cardiac Arrest (THAPCA) Supported by funding from HRSA/MCHB/EMSC - R21 HD R34 HD U01 HL U01 HL094339

36 Pediatric Post-Arrest ICU Hypotension PECARN: 383 children Hypotension (SBP<5%ile within 6 hr): 56% Mortality Hypotension 53% No hypotension 41% Odds of death: 1.71 (95% CI: 1.02, 2.89) Topjian CCM, 2014

37 LV Systolic Function Following OHCA 58 patients admitted to CHOP PICU Echocardiogram within 24 hours of ROSC Decreased function vs Normal Function After controlling for VF and vasopressor scores, patients with decreased function had 13.7 times higher odds of death Conlon, under review, 2014

38 Pediatric Post-CA Hyperoxia 195 pediatric cardiac arrests: survive > 6 h 54% hyperoxia, 22% hypoxia No relationship with survival 74 ped CA: 51% hyperoxia; 14% hypoxia No relationship with survival Statler, CCM 2013 Guerra-Wallace, PCCM 2013 PICANET: n= 1875 : 11% hyperoxia, 24% hypoxia Odds of death 1.25 (95% CI: ) Ferguson, Circulation 2012

39

40 Pediatric Post-Arrest Seizures 19 children treated with hypothermia Seizures 47% Status Epilepticus 32% Severely abnormal background 100% PPV for seizures Electrographic seizures 78% PPV for poor outcome Abend, Neurology, 2009

41 Electrographic Status Epilepticus is Associated with Worse Outcomes MORTALITY OR (95% CI) PCPC OR (95% CI) No Seizures ref ref Electrographic 1.3 (0.3, 5.1) 1.2 (0.4, 3.9) Seizures p=0.74 P=0.77 Electrographic 5.1 (1.4, 18) 17.3 (3.7, 80) Status Epilepticus p=0.01 P<0.001 Controlled for age, sex, acute etiology, EEG background, prior neurodevelopmental abnormality and EEG monitoring indication Topjian, CCM, 2013

42 Pediatric Post-CA Ventilation 195 pediatric cardiac arrests: survive > 6 h 38% hypercapnia, 29% normocapnia, 46% hypocapnia Good vs poor neurologic outcome p = ped IHCA: 13% hypocapnia; 27% hypercapnia Statler, CCM 2013 Hyper: Odds of death 3.27 (p=0.001) Hypo: Odds of death 2.71 (p=0.04) Del Castillo, Resuscitation 2013

43 CPR duration was associated with survival and neurologic outcome. However, providing > 20 min CPR was NOT futile Surgical cardiac patients had the best outcome.

44 Pediatric Survival GWTG-R Matos, Watson, Nadkarni, Huang, Berg, Meaney, Carroll, Berens, Praestgaard, Weissfeld, Spinella. Circulation 2013

45 CPR duration in kids Adjusted probability of survival CPR 1-15 min: 41% CPR >35 min: 12% Among survivors, favorable neuro CPR 1-15 min: 70% CPR >35 min: 60% Matos, Watson, Nadkarni, Huang, Berg, Meaney, Carroll, Berens, Praestgaard, Weissfeld, Spinella, Circulation 2013

46 In search of Adjuncts: Circumferential chest compressions/load Distributing Band Automated Active Compression Decompression CPR Impedance Threshold Device Augmentation ECMO Man AND Machine!

47 Developing A Culture Of Data Collection High Quality Performance Training/ Retraining Reporting/ Benchmarking Feedback (individual & organizational)

48 Rigorous Evidence Evaluation PRACTICE! LOOK AT OURSELVES! What We Know Guidelines and Medical Standards What we teach, learn and remember What we do Patient Outcome = 22% Fact! 80% 95% x 50% 75% x 50% 75% = 54%

49 How Do Teams work Together? Annually 26 attendings 715, X X Possible residents teams nurses How do teams work well together when they don t work together consistently?

50 Compliance with Guidelines Sutton Pediatrics 2009

51 Resuscitation Performance Over Time With Rolling Refresher Training Techniques B Ideal Performance Resuscitation Performance ACLS Training Time

52 Pre-arrest Identification High Risk Clinical Indicators Parshuram 2009 Bonafide 2011 Rolling Refreshers Hands-on practice with defibrillator, chest compressions and ventilations Niles 2009 Sutton 2011a Sutton 2011b Intra-arrest Real-time CPR Feedback MRx/Q-CPR Audio + visual feedback ETCO2 Arterial BP Niles 2008 Sutton 2008 Sutton 2009 Edelson 2011 Abella 2007 Niles 2009 CSI: Code Scene Investigation Code scene forensics Mattress Reconstruction Maltese 2008 Nishisaki 2009 CSD: Code Scene Debriefing Quality of CPR Clinical issues Latent and obvious hazards Examples of excellence Edelson 2008 Dine 2008 Temperature control, Blood pressure/hemodynamics, Oxygen, CO 2, PCA, ECMO, Glucose, ph, electrolytes, Fluid management Sunde 2007 Sunde 2008 Sunde Day 1 Post-Resuscitation Care Day 2-3 Post-Resuscitation Dress Rehearsals Anticipate Challenges, Rehearse Interventions, Review Protocols, Clarify Communication, Document Competence Scholtz 2011 Day 4 Case Debriefing Quality of Care Clinical issues Latent and obvious hazards Barriers to process Examples of excellence Edelson 2008 Dine 2008 Primary Outcome: Return of Spontaneous Circulation Primary Outcome: Survival to discharge Secondary Outcome: Survival to One Year

53 Single CPR Quality Elements 81% 91% 82% 87% p=.19 p< 0.01

54 Primary Outcome: Excellent CPR Percentage of Epochs Excellent CPR (30s) OR: 5.6 (CI , p<0.01) 29 ± 2 61 ± 4 Excellent CPR Epoch Depth 38mm Rate 100 CC/min < 10% leaning >90% CPR fraction p< 0.01

55 Secondary Outcomes Survival to Discharge p =.02 51% Percentage Survival to Discharge % 16/52 22/43 0 Rolling Refresher + Automated Feedback Debrief

56 Secondary Outcomes Neurologic Outcome p =.04 51% 49% 31% 26%

57 Outcomes: Depth 85 IHCAs CPR quality assessed Controlled for time More kids over 8yr survive (> 4x more!) when you perform AHA Compliant CPR * aor 10.3, CI95: , p<0.01 aor 4.21, CI95: , p = Sutton, CCM in press 2014

58 Focused Efforts to Improve Skills Low Intensity High Frequency Environment Team Individual Performance Debriefing Performance Feedback

59 Rapid deployment E-CPR was feasible and successful, with 51% survival. CPR duration was not associated with mortality.

60 Alternative Perfusion Techniques and Conditions to Improve Recovery Controlled Reperfusion Ultrasonic Micro bubbles Direct Peritoneal Resuscitation Rapid and Profound Cooling (Emergency Preservation Resuscitation) Carbon Monoxide Brain Derived Neurotrophic Factor Nannotech guided vascular access Chemical Defibrillation Chemical Hibernation

61 For the Future? Surveillance Early Detection Rapid Response Team Performance Monitoring/Coaching Mechanical/ECMO support? Post-ROSC Care Quality Review

62 Challenges: Recognize Shock, Respiratory Failure..cardiac arrest and ACT Provide Simple, yet Goal Directed (personalized) Advanced Care Best methods to train/help lay and professional rescuers ACT and act well

63 Priorities: Early warning and identification systems to recognize Shock, Respiratory Failure..cardiac arrest and alert to ACT Develop Simple, evidence-based Goal Directed (personalized) tools to target care, with feedback provided Systems of care to help dispatchers, lay and professional rescuers ACT and act well

64 Priorities: Every school should have an Emergency Action Plan (AEP) that includes: every child entering 9 th grade should be trained in CPR and AED use No child left behind the ultimate homeland security

65 Challenges toward 2020 Knowledge Discovery Knowledge Processing Knowledge Transfer Teach Data Learn Data Quality of Life Remember Level of Evidence Quality of evidence Continuous review Act Act well Can it work? Is it feasible and safe? Does it work? Intact Neurologic Survival

66 Key Knowledge Gaps The incidence and etiology of SCD The optimal methods for prevention The role of the school The role of the legislature Other important educational aspects

67 Implementation/Action Strategies Understanding the incidence and etiology Support the CDC-NIH registry in both Phase I and Phase II and beyond The Schools All schools should have an AEP All schools should have a CPR-AED program All students should learn CPR-AED use The Legislature Each state should mandate AEP, CPR=AED in all schools and CPR-AED education for every student

68 Implementation/Action Strategies Other important educational aspects Importance of an autopsy Importance of a molecular autopsy Importance of genetic testing Importance of cascade testing Importance of family support groups in order to help with support and additional education

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