Resuscitation in infants and children

Transcription

1 Resuscitation in infants and children The importance of respiratory support Dr. Simon Erickson Paediatric Intensive Care Princess Margaret Hospital for Children

2 Paediatric cardiac arrests uncommon (~20/100,000) more common in infants primary respiratory aetiology (80%) predominantly asystole/bradycardia/pea (80%), VF/VT (4-14%) survival poor (9-20%) Especially out of hospital functional outcome poor economic and social costs

3 Paediatric Cardiopulmonary Arrests 10% 10% 1 Respiratory Shock 80% 1 Cardiac

4 Paediatric arrests # Arrests Age (years)

5 Arrive in ER in cardiac arrest (N = 80) Admit PICU (N=43) 54 % Died in ER (N=37) 46% Mod Deficit (N=3) PVS at 12 mos (N=2) Dead at 12 mos (N=1) Died in ICU (N=37) 46% Schindler M, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. N Engl J Med 1996;335:

6 Outcome-out of hospital arrests Arrive in ER in cardiac arrest (n = 300) ROSC n=33 (11%) Discharge n=6 (2%) Good outcome n=1 (<1%) Sirbaugh. A prospective, population-based study of the demographics, epidemiology, management and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med 1999.

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9 Outcome: in-hospital arrests Inpatient arrests n=880 ROSC n=459 (52%) Survival 24 hrs n=317 (36%) Survival to discharge n=236 (27%) Good outcome n=136 (15%) Nadkarni et al, First documented rhythm and clinical outcome from inhospital cardiac arrest among children and adults. JAMA 2006

10 Nadkarni et al, First documented rhythm and clinical outcome from inhospital cardiac arrest among children and adults. JAMA 2006

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13 Pre-arrest phase monitoring/prevention/met risk recognition No-flow phase minimise Low-flow phase optimise CPR Post-resuscitation phase Immediate Optimise Hypothermia et al Prevent recurrence Rehabilitation

14 Pulse check Most studies show that neither laypersons nor healthcare professional can reliably detect pulse within 10 seconds In children healthcare professionals detected a pulse accurately in 80% 14-24% mistakenly detected pulse 21-36% missed pulse when present CPR should be commenced when Unresponsive Not breathing No signs of life

15 CPR adverse consequences of compressions rare In any infant or child with HR < 60/min + poor perfusion excellent standard compressions may provide up to 50% of normal cerebral blood flow two thumb encircling-hands technique is the preferred technique in infants Compression: ventilation ratios Rates Basic LS 30:2 Advanced LS 15:2 (2 healthcare workers) 100/minute for infants and children Pause for ventilations until ETT secured

16 Asystole/Bradycardia/PEA Ventilate with O 2 Initiate CPR ADRENALINE 0.1mL/kg 1/10,000 IV/IO OR 0.1mLkg 1/1,000 via ETT CPR 2-4 minutes Intubate IV/IO Access Continue CPR 2-4 minutes Consider IV fluids hypovolaemia hypoxaemia hypothermia hypo/hyperkalaemia toxins tension pneumothorax tamponade thromboembolism ADRENALINE 0.1mL/kg 1/10,000 IV/IO 0.1mLkg 1/1,000 via ETT

17 VF/PULSELESS VT Defibrillate 4J/kg Ventilate O2 CPR 2 minutes Defibrillate 4J/kg CPR 2 minutes Adrenaline 0.1 ml/kg 1/10000 IV/IO Adrenaline 0.1 ml/kg 1/1000 ETT hypothermia hypoxia/acidosis toxins antiarrhythmics congenital QT electrolyte disturbances ischaemia Defibrillate 4J/kg CPR 2 minutes Amiodarone 5mg/kg Witnessed arrest: 3 stacked shocks 2J/kg, 4J/kg, 4J/kg

18 Adrenaline/Epinephrine Action primarily via : coronary perfusion pressure 1 : contractility, automaticity, VF intensity Side effects: myocardial O 2 consumption myocardial dysfunction post-arrest hyperadrenergic state 1991 large dose (200 g/kg) A/W survival & neuro outcome in single non-blinded trial of 20 children Subsequent studies retrospective RCT 2003 (n=50) ROSC 24-hour surv. Discharge HDE SDE

19 Amiodarone in VF / Pulseless VT Amiodarone for resuscitation after out-of-hospital cardiac arrest due to VF Kudenchuk et al, NEJM, 1999 Seattle 94-97, 500 adults randomised on presentation survival to admission (44% Vs 34%, OR 1.6 p=.02) but not survival treatment for hypotension (59% Vs 48%) or bradycardia (41% Vs 25%) with amiodarone Amiodarone as compared with lidocaine for shock-resistant VF Dorian et al, NEJM 2002 RCT, n=347, out-of-hospital arrest amiodarone increased survival to admission (22% vs. 12%) survival to admission (27.7% vs. 15.3%) in those given drug in less than median time Limited experience in children

20 Defibrillation Biphasic defibrillators now widely available decrease impedance, thus less peak current required may be as effective at less current with less myocardial injury Mostly animal data Current recommendations 150 joules for adults 2-4 J/kg for children

21 Defibrillation Stacked shocks vs.single shock Long pauses in compressions assoc. with worse outcomes Relatively high initial success rate Joules (2-4 J/kg) Low success rate in termination of VF in children with 2 J/kg Threshold in animal studies J/kg Paddle size Size inversely proportional to impedance Position No difference in impedance with paddle position

22 AED s in infants and children Many AED s can safely distinguish between shockable and non-shockable rhythms in infants Young myocardium may tolerate high energy doses Recommended order of preference Manual defibrillator AED with dose-attenuator AED without dose attenuator

23 Paediatric BLS sequence SAFE approach Are you OK? Airway opening manouvres Look, listen, feel Up to five breaths Check pulse Start CPR 1 minute Call emergency services ie phone fast

24 Rescue Breaths No data to support any single number of initial rescue breaths Two initial effective breaths should take priority. ideally a pause between each breath for the rescuer to take a breath BLS competency should include the skill of using bag valve mask device Resus bags for full term newly born infants should have a minimum volume of ml

25 Oxygen Good evidence supporting use of room air vs. 100% O2 in newborn resuscitation Several animal studies suggesting improved neurological outcome with room air resus Insufficient evidence in children to support any specific level of oxygen

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28 Nasopharyngeal Airway Length: Nostril to Tragus Contraindications: Basilar skull fracture CSF leak Coagulopathy

29 Oral Airways

30 Airway Positioning Sniffing Position In the child older than 2 years Towel is placed under the head

31 Laryngeal Mask Airway In adults easier to master than intubation, in children training & supervision needed to master technique of insertion Range of sizes Airway not actually protected from aspiration Difficult to maintain during patient movement Relatively expensive Limited data in children not recommended in children during resuscitation

32 Bag-mask ventilation vs. intubation Intubation at scene by paramedics No difference in outcome in children after cardiac or respiratory arrest Higher risk of mortality or neurological disability in trauma patients Higher rate of intubation failure in children cf. adults

33 Cuffed vs. uncuffed endotracheal tubes No studies looking at emergency intubation Randomised trials in the paediatric anaesthesia setting show that cuffed ETT Increase likelihood of correct sizing Don t increase the risk of airway complications May reduce risk of aspiration May reduce air leak in burns patients

34 Minute ventilation Ventilation during CPR increased ROSC, survival, neuro outcome in animal studies Excessive ventilation is common in adult resuscitation There are no data in children to identify optimal minute ventilation during resuscitation

35 ETCO2 Good adult evidence (and some evidence in paeds) that ET CO 2 level correlates with effectiveness of ECM & prognosis ET CO 2 and outcome of out-of-hospital cardiac arrest Levine et al, NEJM, 7/97: ET CO 2 < 10mmHg at 10 mins = 100% predictive Strong correlation between ETCO2 and interventions that increase cardiac output Association between low ETCO2 (<15mmHg) and failure to ROSC after mins resus

36 Post-resuscitation care Optimise organ perfusion Minimise organ stress Alteration of cytotoxic processes Therapeutic hypothermia Neuroprotective agents Experimental agents Prediction/assessment of outcome SSEP s EEG Rehabilitation

37 Hypothermia Animal studies have demonstrated that hypothermia is a potent neuroprotective therapy Cerebral metabolism Apoptosis, calpain mediated proteolysis, mitochondrial injury Ion pumps and neuroexcitatory cascade Immune response and inflammation Free radical production Vascular permeability, oedema formation, vasc reactivity Cerebral thermo-pooling

38 Therapeutic hypothermia Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia Bernard et al, NEJM 2002 therapeutic hypothermia (33 deg. for 12 hours) improved survival to rehab or home (49% vs. 26%), adjusted OR 5.25 (1.47, 18.76) hypothermia CI, SVR, glucose Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest HACASG, NEJM 2002 therapeutic hypothermia (32-34 for 24 hours) resulted in improved neurologic outcome (CPC 1,2) 55% vs. 39% (OR 1.4) improved mortality at 6 months (41% vs. 55%) OR 0.74 (0.58, 0.95) Multinational pilot trial (HypCAP) underway in children

39 Human HIE Studies At least 4 neonatal studies underway, all cooling for 72 hours Two completed neonatal studies positive Effect highly related to pre-randomisation amplitude integrated EEG No effect if severely abnormal Large effect if moderately abnormal OR 0.42 ( ), 58% relative reduction in severe disability Reduced loss of grey matter

40 When should resuscitation be stopped? Discontinue if ROSC not achieved after 30 minutes of asystole unless special circumstances refractory VF or VT toxin exposure electrolyte imbalance hypothermic injury

41 Family presence during resuscitation Most families want option to be present during resuscitation Most families reported that being present was beneficial Most studies suggest this is not harmful but one reported short term emotional difficulties

42 Role of simulation training

43 Alpha-NME Experimental data short-acting alpha-2 adrenergic agonist improves post-resuscitation ejection fraction Adrenergic receptor blockade both -blocker (prazosin) and -blocker (propranolol) and combination given with epinephrine reduced post-resuscitation myocardial dysfunction Biochemical markers post-arrest troponin levels are proportional to myocardial dysfunction post-resuscitation both in animals and children non-specific enolase, S100-B Anti-oxidants/Room air resuscitation Modulating excitotoxicity Inducing hibernation Apoptosis Cold aortic flush

44 Conclusions Resuscitation medicine not an strong evidencebased area, especially in paediatrics Outcome of paediatric cardiac arrest remains poor Oxygenation of primary importance in resuscitation in infants and children Both as a cause and a remedy Identification of risk factors and prevention a more effective strategy Dealing with patient, family and staff crucial following both successful and unsuccessful resuscitation